The Yorkshire Clinic
Quality Account
2012/13
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Welcome to The Yorkshire Clinic
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
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Appendix 3 – Glossary of Abbreviations
Quality Accounts 2012/13
Page 2 of 36
Welcome to Ramsay Health Care UK
The Yorkshire Clinic 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 117 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 38 acute hospitals and day surgery facilities.
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 on average over
1,000 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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Welcome to The Yorkshire Clinic
The Yorkshire Clinic is a private hospital situated in the grounds of Cottingley Hall in
Bingley, West Yorkshire. The hospital offers care to patients with private medical
insurance, patients who wish to fund their own treatments and patient referred through
the NHS Patient Choice Scheme.
The hospital provides a full range of high quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months the hospital has treated 13,419 patients, 70.7% of
which were treated under the care of the NHS.
The Yorkshire Clinic has 354 members of staff with a split of 147 non-clinical staff and
207 clinical staff.
The hospital has built excellent working relationships with local Commissioner and
Bradford Hospitals Foundation Trust, Leeds Teaching Hospital NHS Trust and Airedale
Foundation Trust in order to deliver a joint approach to patient care delivery across the
patient economy.
Our GP Liaison Officer provides links to local General Practitioners to ensure that their
needs and expectations are managed and through these links referral processes are
developed in order to streamline processes.
The Yorkshire Clinic also works with charities within the local community, hosting
events in their support.
Introduction to our Quality Account
This Quality Account is The Yorkshire Clinic’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all committed
to providing continuous, evidence based, quality care to those people we treat. It will
also show that we regularly scrutinise every service we provide with a view to improving
it and ensuring that our patient’s treatment outcomes are the best they can be. It will
give a balanced view of what we are good at and what we need to improve on.
Within this report the team at The Yorkshire Clinic have clearly identified that their focus
has remained constant on improving services for our patients, working with the local
commissioners to identify key health issues affecting the local community and how the
team can help to improve outcomes for all our patients.
Quality Accounts 2012/13
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Part 1
1.1
Statement on quality from the General Manager
Mike Flatley, General Manager,
The Yorkshire Clinic
“The Yorkshire Clinic understands that you have a choice and is committed to
being the leading healthcare provider of choice by delivering high quality care
and outcomes for patients.”
This is the third Quality Account to be submitted by The Yorkshire Clinic and has been
produced to demonstrate our commitment to measuring all feedback from patients
about their experience, clinical treatment and clinical outcomes. This allows us to
continually review, reflect and improve the patient’s journey.
We are aware that patients can be nervous about coming into hospital and understand
that providing reassurance is important to you the patient. This starts with patient
safety, which is our highest priority. To this end we recruit, induct and train our team to
the highest standard in all aspects of care. This approach extends to family and visitors
in ensuring they are made to feel welcome at the Yorkshire Clinic.
The Yorkshire Clinic continually achieves consistent patient satisfaction scores of over
98% for recommendation to others and for overall satisfaction. By analysing the results
throughout the year, we constantly seek ways to further improve the patient experience.
The Yorkshire Clinic is committed to ensuring that patients are kept fully informed about
their treatment, which is also a significant factor associated with improving treatment
outcomes. We involve our patients in treatment decisions at the earliest stage so that
the options and benefits are fully discussed before patients consent to treatment. Our
medical and clinical teams recognise the importance of devoting time preparing
patients for surgery, which not only reduces risk but also improves patient
understanding and confidence, reduces anxiety, improves rates of recovery and
shortens lengths of hospital stay.
Whilst patient feedback and involvement is extremely important to us, we also rely
heavily on other measures of safety and clinical effectiveness which we use to satisfy
ourselves that treatment is evidence-based and delivered by appropriately qualified and
experienced doctors, nurses and other key healthcare professionals. Examples of
these are detailed in this Quality Account.
The Yorkshire Clinic is accustomed to the disciplines of regulatory and contractual
requirements to assure healthcare commissioners of our clinical performance and to
report complaints and serious incidents to regulators and commissioners. We also
maintain a Risk Register and systematically review specific actions to achieve risk
reduction.
Quality Accounts 2012/13
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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.
Mike Flatley
General Manager
The Yorkshire Clinic
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr James Halstead – Medical Advisory Committee Chair
Mr Richard Grogan - Clinical Governance Chair
Mr Stefan Andrejczuk – Regional Director North
Quality Accounts 2012/13
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Part 2
2.1 Quality priorities for 2012/2013
Plan for 2012/2013
On an annual cycle, the Yorkshire Clinic develops an operational plan to set objectives
for the year ahead. The main focus for the coming year is to ensure that the patient is
at the centre of everything we do.
We have a clear commitment to our patients and work in partnership with the NHS,
ensuring that those services commissioned to us result in safe, quality treatment for all
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 on-going 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 Setting clinical priorities for 2013 - 2014
Bar coding for patient identity bands – The Yorkshire Clinic electronically
prints all patient identity bands as per the NPSA ‘Standardising Wrist Bands
Alert’ issued in 2007. The need for Bar Codes on patients wristbands will be
reviewed by the Ramsay Information Governance Committee prior to the
proposed implementation date of September 2013
Safer Surgery Checklists – The WHO safe surgery checklist is in use for all
surgical procedures including cataract treatments and radiological
interventional procedures. This will continue to be a clinical priority and will be
audited regularly to identify any variance from the Ramsay policy.
Cleanliness - Environmental audits will continue to be undertaken quarterly
as per Ramsay national audit programme. The hospital wide cleaning matrix
will continue, informing staff what needs cleaning when, with what and by
whom. The ‘Green label’ system is to remain, clearly evidencing to patients
when equipment has been cleaned by indicating the cleaning date and the
signature of the person who cleaned it. This year The Yorkshire Clinic will take
part in Patient Led Assessment of the Care Environment (PLACE) which
builds on the foundation of The Patient Environment Action Team (PEAT)
assessments, with two main differences:
-
Patients make up at least 50% of the assessment team giving
patients a much stronger voice.
Focus is on improvement with hospitals required to report publicly
and say how they plan to improve.
Quality Accounts 2012/13
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Joint Advisory Group (JAG) - The Yorkshire Clinic Endoscopy Suite will
continue to participate in the Global Rating Score audit system (GRS).In
March we had a JAG accreditation visit and were awarded a pass on
completion of some minor recommendations. We were given six months to
achieve these recommendations and fully expect to achieve this within four
months.
The competency skilled endoscopy team are supporting the development of
opening evening and weekend clinics in addition to a one stop endoscopy
service.
Day Case to OPD - The Yorkshire Clinic is introducing changes to improve
the patient experience throughout their journey on the day of surgery. In 2013
one of the main improvements being introduced is around ‘minor procedures’
being undertaken as an outpatient appointment rather than as an in-patient.
Selected procedures will be undertaken in our out patients department under
local anaesthetic which will greatly reduce the amount of time patients need to
spend in hospital. Procedures being considered for this are hysteroscopy;
cystoscopy and minor skin lesion procedures
Ligament Registry – The Yorkshire Clinic plans to participate in a National
Ligament Registry through our cohort of Orthopaedic surgeons performing
Quality Accounts 2012/13
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ligament surgery. The governance and data collection processes are
currently being determined with a view to commence this in the autumn of
2013.
Friends & Family Test - A NHS-wide ‘friends and family’ test to improve
patient care and identify the best performing hospitals in England was
announced in 2012 by the Prime Minister.
From April 2013 patients at The Yorkshire Clinic will be invited to take part in
this anonymous survey. By completing a simple questionnaire asking whether
they would recommend our hospital to their family and friends. Scores will be
published on the NHS Choices Website www.gov.uk
Alongside providing clinical excellence and safe care, patient experience is
the key measure of quality. The Yorkshire Clinic will use the information
received from our patients in this survey in order to improve the service we
offer.
2.1.2 Clinical Priorities for 2013/14
Patient Safety
1.
Falls – To maximize patient safety our routine practice is that all patients are
asked to complete a medical questionnaire; this is assessed by the Pre-operative
Assessment Team to identify any potential risks prior to admission. On admission
a “risk of falls assessment” is performed for every patient by the admitting nurse,
this is reviewed daily and care altered accordingly. Information for patients on how
to minimize the risk of falls following surgery/ procedures is available in the patient
information folder in every room. Any slip, trip or fall is reported through our
robust electronic RISKMAN Reporting system identifying any trends, formulating
and implementing action plans across the hospital to help improve patient safety.
Slips, trips and falls recorded/reported during 2010 totalled – 7 and during 2011 18. The chart below shows the number of reported slips trips and fall for 2012-13
were 26; compared figures for 2010 and 2011. The figures show an increase in
incident reporting, reflecting a raised awareness and improved reporting of actual
incidents on our Riskman system.
Actions have been put in place to address the increase in 2012, namely;
Further staff training in risk assessment of patients specifically related to
movement and sensation of all aspects affected limbs after surgery.
Patient manoeuvres post surgery are undertaken only following risk
assessment with two staff members of staff present.
Competency training provided by physiotherapists for all nurses & Health care
assistants in specific risk assessment relating to the effects of regional
anaesthesia.
2.
‘Never Events’
Never events are serious, largely preventable patient safety incidents that should
not occur if the available preventative measures have been implemented. For
Quality Accounts 2012/13
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further details see:
http://www.nrls.npsa.nhs.uk/resources/collections/never-events.
The core list of “never events” includes:
- Misplaced naso or orogastric tube not detected prior to use
- Retained instrument post-operation
- Intravenous administration of mis-selected concentrated potassium
chloride
- Wrong site surgery
- Inpatient suicide using non-collapsible rails
There were no never events at The Yorkshire Clinic during 2012/13.
3.
VTE risk assessment (venous thrombo-embolism)
The Yorkshire Clinic carry out a VTE risk assessment on all admitted surgical
patients as per Ramsay Policy No CM001 and adheres to National Institute for
Clinical Excellence (NICE) Guidance 2010. All our pre-assessment staff has
completed VTE competency assessment via Department of Health on line
assessment tool and the majority of ward based nurses completed this
competency package in 2011.
From 1 April 2013 The Yorkshire Clinic entered into a contract for the provision of
NHS services through the Commissioning for Quality & Innovation Payment
Framework (CQUINs). Payment is conditional on achieving quality improvement
and innovation goals, this includes VTE risk assessment. Compliance is audited
through a robust corporate and local audit programme and results/action plans
reviewed through Clinical Governance. Compliance results are benchmarked
through the National Statistics at
http://transparency.dh.gov.uk/category/statistics/vte/
VTE risk assessment data as published by Unify for 2012/13
100%
1
98%
0.98
96%
0.96
94%
0.94
92%
0.92
90%
0.9
88%
0.88
Fail
86%
0.86
Actual
84%
0.84
Target
82%
0.82
80%
Excellent
Good
0.8
Yorkshire Clinic
including Lodge
The Yorkshire Clinic achieved performance of 99.7% as reported in quarter 3,
which an excellent achievement.
Quality Accounts 2012/13
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4.
Infection Control
The Yorkshire Clinic understands that Infection Control is a core part of an
effective risk management programme, aiming to improve the quality of patient
care and the occupational health of staff, in addition to the clinical need to prevent
Healthcare Associated Infections (HCAI), and protect patients from harm.
The Yorkshire Clinic infection control processes are coordinated and led by an
experienced Registered Nurse who has undergone further training in this field.
The Yorkshire Clinic Infection Prevention & Control Committee comprises of
Consultant Microbiologist, Infection Control Lead; Hospital Matron; CSSD
Supervisor; Hospital Engineer; Hotel Services Manager; Pharmacy Manager and
Link Nurses from Theatre, Wards, Outpatients and Endoscopy.
Meetings are held quarterly and provide the hospital with infection prevention
advice and guidance in conjunction with Ramsay Infection Prevention & Control
Policies and Procedures and National Guidance. All staff undertake mandatory
annual e-learning and practical training sessions for Infection Prevention and our
Consultant Microbiologist also provides bi-annual in house training.
A comprehensive infection control audit programme has been maintained
throughout 2012/2013.
Audits undertaken during 2012/13 achieved average scores of: PEAT
Hand hygiene
Environment cleanliness
Surgical site infection
Central venous catheter care
Peripheral venous catheter care
Urinary catheter care
96 %
100%
95%
100%
100%
93.5%
99.5%
The Infection Prevention & Control Audits have shown improvement in the
following areas: -
-
Audit of insertion and care of central venous catheters continue to
show high compliance to best practice guidelines
Improvement with Surgical Site Infection practices have been seen
with audit results consistently at 100% throughout 2012/13
The Yorkshire Clinic participated in a national Ramsay Hand
Hygiene Day on the 10th May 2012. The day was very successful
involving staff, Consultants patients and visitors promoting best
practice in hand hygiene through games; quizzes and practical
sessions.
The Yorkshire Clinic regularly audits surgical site infections across
surgical specialities using the Department of Health (2010) High
Impact Intervention care bundle tool, to prevent surgical site
infection. This audit focuses on the pre-operative and peri-operative
practice. The audit results during 2012/2013 were 100% compliance.
Quality Accounts 2012/13
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Action plans have been compiled to address issues raised in all the above audits
and can be obtained by contacting the Infection Control Lead at The Yorkshire
Clinic – lynne.taylor@ramsayhealth.co.uk or 01274 550600.
-
-
5.
An improvement in peripheral venous catheter care of 11% compliance from
88% May 2012 to 99% in September was seen as a result of increasing staff
awareness of good practice; regular peer review by Link Nurses and high
profile within team meetings.
Issues raised from the Environmental Audit were in relation to décor and they
are currently being addressed as part of The Yorkshire Clinics refurbishment
programme for 2012/2013. A new Patient Registration Desk has been built
within the Outpatient Department and all Consulting Rooms have been
redecorated and upgraded during the year. Refurbishment of patient rooms
on Ward 1 is currently underway and will see a general upgrade in facilities
and the introduction of a clinical hand wash sink in patient rooms to improve
infection prevention at The Yorkshire Clinic.
Real time incident reporting – The Yorkshire Clinic strives to report any
incidents in real time through the RiskMan System. Every clinical incident is
promptly reviewed by Matron and an investigation process and root cause
analysis undertaken where appropriate. The RiskMan system immediately reports
any incident into the Corporate Risk Management Team allowing the identification
of trends at the Yorkshire Clinic and throughout the Ramsay organization. Locally
all incidents are reported through Risk Management and Clinical Governance
groups, learning’s and action plans developed and implemented at a local level to
improve safety.
Other National reporting mechanisms e.g. MHRA; CQC; local NHS network are
used as required following specific incidents alerting nationally recognised
organisations of identified risks.
6.
National Joint Registry – The Yorkshire Clinic participates in the National Joint
Registry audit programme (NJR). Patients undergoing hip or knee replacement
surgery are asked to consent to their information being placed upon the NJR
including details of their prosthesis. The NJR provide a quarterly report to the
Hospital regarding compliance.
7.
Staff satisfaction – Our latest ‘The Leadership Factor’ Staff Survey was a
positive step forward. Some of the key points are
-
8.
Achieving an 80% completion rate compared to 37% last time the survey
was carried out
73% of staff at The Yorkshire Clinic believe that staff engagement and
motivation are of great importance to Ramsay
62.2% of staff felt proud to work for The Yorkshire Clinic
Acute Care Competencies / Vulnerable Adult training – This ensures that our
patients are safe and being cared for by competent knowledgeable staff who will
not cause any harm. The Yorkshire Clinic staff complete annual mandatory
training programmes in vulnerable adult training, and an additional e learning
package supplied by an external company Kwango. A flow chart has now been
developed and is displayed in each department which provides quick access
Quality Accounts 2012/13
Page 12 of 36
information for staff to know who to contact or what to do if they have concerns
regarding adult abuse issues. The designated nurse is Matron.
Clinical Effectiveness
1.
Ambulatory Day Care – better outcomes and improving patient experience –
Ambulatory Care (or Day Care Surgery) 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 an in-patient stay. In 2012 the percentage of day
surgery patients we treated was 79.8%.
In addition the Yorkshire Clinic has reviewed the procedures it performs as day
cases under local anaesthetic, and where appropriate has converted these
procedures to outpatient attendances to promote an earlier discharge from
hospital.
At the Yorkshire Clinic we aim to ensure that 100% of our Ambulatory Day Care
patients will be treated following one of our ambulatory care facilities. In order to
achieve this The Yorkshire Clinic provides patients with a more efficient journey
through the hospital which includes procedure specific pathways.
We have a dedicated day surgery facility that is separate from our in-patient
facility, best practice has shown that this improves waiting times and recovery
periods are reduced. We monitor the ambulatory day care experience through our
patient satisfaction surveys.
2.
Improve National Benchmarking - It was recognised that we needed more
transparency between ourselves and other independent sector providers/the NHS
in order to monitor and improve our services. Benchmarking is carried out in the
following areas:
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). The Hellenic project is the Independent Healthcare
Advisory Services (HAS) and NHS Partners network in partnership with
Dr Foster project.
Venous Thrombus Embolism (VTE) risk assessment compliance
through NHS Safety Thermometer current compliance rate can be
found at - http://transparency.dh.gov.uk/category/statistics/vte/
Patient Reported Outcome Measures (PROMS) results benchmarking through national PROMS website link as follows http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=19
37&category
Patient satisfaction - The Yorkshire Clinic asks all patients to complete
a ‘We Value Your Opinion’ leaflet to enable us to collate patient opinion
and act immediately upon any concerns.
Quality Accounts 2012/13
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As a direct result of the comments received from the ‘We Value Your
Opinion’ questionnaires the following are some examples of how we
have improved care:
- Our Hotel Services Manager and Chef regularly visit
patients following admission to discuss and receive
feedback on the quality of food and the options available.
- Our Facilities Manager is currently coordinating a full
refurbishment programme of patient areas.
- Additional parking has been sourced off site for members
of staff giving extra car parking spaces for our patients
An improvement in overall hand hygiene patient perception has been seen in
2012 achieving an average of 97.75% compared to 95.9 in 2011.
Patient satisfaction with cleanliness, an average score of 99% has been
maintained during 2012 with the Yorkshire Clinic scoring over 98% for each
quarter.
3. Improve ward efficiency by adopting the Productive Ward initiative –
“more time to care”
The ward has improved efficiencies for patients on the ward by looking at different
ways of working; this is in line with the Productive Ward initiative - "more time to
care". The priority this year has looked at the patient journey and staffing rota's,
The shift patterns have been completely changed with a combined outcome of
providing an improved experience for patients and a better work balance for staff,
this is by looking at a four day week rather than five day week for staff which for
day case patients means that there is no handover of care from one shift to the
next therefore day case patients have continuity of care throughout their
experience. This works well for both morning and afternoon lists with staff arriving
at 11.30am in time to prepare for the lunchtime lists and stay until the last patient
is discharged home.
4. Improved patient communication and information
Patient Satisfaction is an essential way of improving services at The Yorkshire
Clinic and this year the focus has been on discharge information, we focussed on
providing patients with procedure specific information following the previous years
feedback and earlier this year the Patient Survey identified that patients were not
always feeling that they felt that care following discharge was as good as it could
be and that medication was not always explained. We have a business card that
is now given to all patients on discharge and patients are actively encouraged to
contact the hospital if they have any concerns. We give verbal information
regarding discharge medication combined with a "managing your pain"
information leaflet which explains the analgesia ladder and how they should use
the different analgesia they have been discharged with.
This year’s compliments strongly reflect that we are improving our discharge
communication with comments including "all questions answered, thoroughly
explained, information helpful, plenty of advice, helpful and informative, thorough
Quality Accounts 2012/13
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in every aspect" being received as the norm in our we value your opinion leaflets
that are given to every patient on discharge.
Patient experience – informing patient choice
Increasing the use of Patient Reported Outcomes Studies (PROMs) – The
Yorkshire Clinic routinely issues the National PROMS questionnaires to patients
undergoing hip, knee, hernias and cataract surgery (PROMs for Hip’s, Knees and
Hernia Repairs are reported by The Yorkshire Clinic). These are used to gain a better
understanding of treatment outcomes from a patient point of view. Compliance for
PROMS is above the national average at The Yorkshire Clinic. The PROMs scores for
the Yorkshire clinic can be found on page 30. Consultants can access this information
within their own Trusts for all patients, including those treated at The Yorkshire Clinic.
Patient Satisfaction survey
Patients are asked 2 infection control questions on the Patient Surveys
1. Did the healthcare staff always wash their hands or use alcohol gel before treating you?
2. Were you satisfied with the level of cleanliness in the hospital?
An improvement in overall hand hygiene patient perception has been seen in 2012/13
achieving an average of 97.75% compared to 95.9% in 2011. For patient’s satisfaction
with cleanliness, an average score of 98.9% has been maintained throughout the year.
An area for development identified from our patient satisfaction survey was that
patients felt that they were not kept informed of waiting times for theatre, this has been
addressed in a number of ways, the ward and theatre staff liaise before the start of the
morning and afternoon lists regarding any changes and if there are any unrealistic
theatre times scheduled, patients are then informed of their approximate theatre time
and if there are any significant changes during the list the patients are notified. We are
currently benchmarking ourselves against other hospitals and how they manage the
same problem. We are looking at staggering theatre admissions for patient
convenience wherever this is appropriate.
Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2012/13 the Yorkshire Clinic contracted to deliver 17 NHS services.
The Yorkshire Clinic has reviewed all the data available to them on the quality of care in
all of these NHS services which include:






Anaesthetics
Audiology
Bariatrics
Dermatology
ENT
Gastroenterology
Quality Accounts 2012/13
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











General Surgery
Gynaecology
Haematology
Neurology
Neurophysiology
Ophthalmology
Oral Surgery / Restorative Dentistry
Oral and Maxillo Facial
Orthopaedics
Pain Management
Sleep Studies
Urology
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 and the scorecard is reviewed each quarter by the hospitals senior
managers together with Regional and Corporate Managers. The balanced scorecard
approach has been an extremely successful tool in helping us benchmark against other
hospitals and identifying key areas for improvement.
In the period for 2012/13, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources
Total Health care Assistants – whole
time equivalent (WTE)
Total Registered Nurses (WTE)
Total WTE Nursing (RN & HCA)
HCA hours as a % of Total Nursing
Hours
Rolling Sickness Absence
Rolling Employee Turnover
Number of Significant Staff Injuries
2010/2011
21.92
2011/2012
17.59
2012/2013
21.97
60.34
82.26
26.64
56.72
74.31
26.67%
56.75
78.72
28%
4.84%
5.4%
1 (RIDDOR
reportable)
4.53%
4.7 %
1 (RIDDOR
reportable )
3.66%
6.0
0
The ratio of qualified nurses to health care Assistants has altered recently due to
improvements in training and recruitment of Health care assistants to provide additional
competency skilled ability to more effectively support the Registered nurses to deliver a
higher quality of care.
Patient
Formal complaints:
The Yorkshire Clinic received 61 complaints from 1 April 2012 to 31 March 2013 (which
was 0.46% of patients treated at The Yorkshire Clinic). All of these were investigated
meeting all of our timetables around response. There were no common themes or
significant concerns arising from the complaints received.
Quality Accounts 2012/13
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98% of patients treated at the Yorkshire Clinic from 1 April 2012 to 31 March 2013
stated they were treated with dignity and respect by The Yorkshire Clinic. This is an
excellent achievement.
There were no EMSA (Eliminating Mixed Sex Accommodation) breaches throughout
2012/13.
Quality
A comprehensive Health, Safety and Facilities audit was carried out at the Yorkshire
Clinic by the Estates Manager and the Ramsay Group Estates Manager on the 19 th
November 2012. This audit returned a score of 97%. This shows an improvement from
the last Audit which scored 90% compliance in 2011.
2.2.2 Participation in Clinical Audit
During 1 April 2012 to 31 March 2013, 5 national clinical audits covered NHS services
that The Yorkshire Clinic provides.
Name of Audit
Cardiac Arrest (National
Cardiac Arrest Audit)
Hip,Knees and ankle
replacement (National Joint
Registry)
Elective Surgery (National
PROMs programme)
Health Protection Agency –
Surgical Site Surveillance
NHS Safety Thermometer
Participation
(NA, No,
Yes)
N/A
Yes
% cases
submitted
Comments
N/A
100%
Yes
100%
Yes
100%
Yes
100%
Hip & Knee
Replacement
The reports of 5 national clinical audits from 1 April 2012 to 31 March 2013 were
reviewed by the Clinical Governance Committee at The Yorkshire Clinic.
Local Audits
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme (the
schedule can be found in appendix 2) the audit topic and schedule is set centrally by
Ramsay Health Clinical Governance Committee to allow greater opportunity for
benchmarking. Additionally the Yorkshire Clinic also carries out a number of local
clinical audits all of which go through the Clinical Governance Committee where actions
are taken to improve the quality of the healthcare provided:-
-
Infection Prevention Audits: The Yorkshire Clinic has followed the corporate
audit programme throughout the year and results have shown improvement in
hand hygiene and care of peripheral venous catheter with scores rising to 100%
and 99% respectively.
Cardiac Arrest Scenario, which involves an unannounced artificial cardiac
arrest situation using a resuscitation dummy. The routine emergency process
occurs in the hospital and a resuscitation lead assesses the care and treatment
Quality Accounts 2012/13
Page 17 of 36
-
-
-
-
provided and learning outcomes are shared and improvements made where
appropriate.
Critical Care Trolley Audit: To ensure that emergency equipment is ready for
immediate use a check of defibrillator, oxygen and suction is undertaken daily.
There is also a weekly audit of the critical care trolley.
WHO – surgical safety check Audit: This is incorporated into the care record
for every patient and there is an additional audit to monitor compliance with the
checklist. The audit assesses that clinical staff are routinely checking that the
correct patient, receives the correct surgery on the correct site, and the patient
has been appropriately prepared and consented for the procedure planned.
Consent Audit: Assesses the consent process in 2 stages. Stage one ensures
that patients are provided with sufficient information to provide informed consent.
Stage two confirms that the patient is happy to proceed having had time to
consider the information provided.
Clinical Variances & Outcomes: All clinical variances indentified where there is
a variance from the norm, i.e. extended length of stay, readmission to hospital or
return to the operating theatre are documented and reported, to support a review
and discussion in monthly clinical governance forums and Medical advisory
committees. These forums which are held by a group of experienced clinician’s,
support the discussion of trends and concerns relating to practice in general or
the practice of an individual practitioner and advice and changes in practice can
be implemented.
2.2.3 Participation in Research
Research is a core part of the NHS, enabling the NHS to improve the current and future
health of the people it serves. ‘Clinical research’ means research that had received a
favourable opinion from a research ethics committee within the NRES information
about clinical research involving patients is kept routinely as part of a patient’s records.
Ramsay healthcare does encourage participation in research and there is a clear policy
and framework to support and direct this, however the Yorkshire Clinic has not received
any applications for clinical research in 2012 – 2013 and did not treat any patients who
were participating in any clinical research studies.
2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning
for Quality and Innovation) Framework
The CQUIN payment framework aims to support the cultural shift towards making
quality the principle of NHS services, by embedding quality at the heart of
commissioner/provider discussions. It is an important lever, supplementing Quality
Accounts to ensure that local quality improvements are discussed and agreed at board
level within/between organisations. It makes a provider’s income dependent on locally
agreed quality and innovation goals.
The following CQUINs targets have been agreed for 2013/14 between The Yorkshire
Clinic and Bradford District CCG and Associate CCG’s;
Quality Accounts 2012/13
Page 18 of 36
Indicator Indicator Name
Number
National Indicators
1
Friends and
Family Test
(FFT)
Quality Domain
Description of
Indicator
Indicator
Weighting
Clinical & Quality
Effectiveness
10%
2
NHS Safety
Thermometer
Clinic/ Quality
Effectiveness
3
Venous
Safety Clinical
Thrombembolism Effectiveness
(VTE)
4
Service
Transformation
Quality
Effectiveness
5
Patient
Experience
Clinical/Quality
Effectiveness
To improve the
experience of
patients in line with
domain 4 of the NHS
outcomes
framework. The
friends and family
test will provide
timely, granular
feedback from
patients about their
experience.
To reduce harm. The
power of the NHS
Safety Thermometer
lies in allowing
frontline teams to
measure how safe
their services are
and to deliver
improvement locally
To reduce avoidable
death, disability and
chronic ill health from
venous
thromboembolism
(VTE)
Alternative to faceto-face contact and
day case to
outpatient
procedures
Condition specific
consent
5%
10%
65%
10%
The NHS Institute website is available to share CQUIN schemes for further information.
(http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
2.2.5 Statements from the Care Quality Commission (CQC)
The Yorkshire Clinic is required to register with the Care Quality Commission and was
last inspected on the 23rd January 2013. 5 essential standards of quality and safety
were assessed of which 4 were fully compliant and one was identified as requiring
improvement. Whilst all patients were consented for care and treatment, there was a
minor improvement required, in that consent was not always obtained following a 2
stage process. A comprehensive action plan has been submitted to the CQC to
confirm how the hospital will achieve full compliance within a timely period. The report
can be found on the CQC website: http://www.cqc.org.uk/directory/1-128733159
2.2.6 Data Quality
Quality Accounts 2012/13
Page 19 of 36
Good quality information underpins the effective delivery of patient care and is essential
if improvements in quality of care are to be made. Improving data quality, which
includes the quality of ethnicity and other equality data, will thus improve patient care
and improve value for money.
Statement on relevance of Data Quality and your actions to improve your Data
Quality
At The Yorkshire Clinic data quality is one of our highest priorities to ensure we
produce clean and accurate electronic data which we can use to monitor and improve
our quality of care and service. Throughout the year we have updated and
strengthened our processes to capture data in a timely manner and to audit data prior
to submission. We are constantly looking to improve data capture and reporting
processes supported by a dedicated corporate quality team.
NHS Number and General Medical Practice Code Validity
The Yorkshire Clinic submitted records during 2012/13 to the Secondary Uses service
for inclusion in the Hospital Episode Statistics which are included in the latest published
data. The percentage of records in the published data which included:
The patient’s valid NHS number was correct:
99.7% for admitted patient care;
99.3% for outpatient care;
The General Medical Practice Code was correct for
99.9 % for admitted patient care;
99.8% for outpatient care;
Clinical coding error rate
The Yorkshire Clinic employs a full time Clinical Coder who is responsible for all
procedure coding. Internal clinical coding audits are performed on a regular basis and
all coders are required to undertake regular training and development to ensure all
changes in coding are identified and embedded into our processes.
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall 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/
Quality Accounts 2012/13
Page 20 of 36
2.2.7 Stakeholders views on 2012/13 Quality Account
Quality Accounts 2012/13
Page 21 of 36
Quality Accounts 2012/13
Page 22 of 36
Yorkshire Clinic 2012-2013 Quality Accounts
We welcome the opportunity to comment on this Quality Account and wish to thank the
Matron at the Yorkshire Clinic (YC) for being helpful and open to our queries
We very much applaud a number of examples of good practice at the Yorkshire Clinic (YC)
including the use of the WHO safe surgery checklist for all surgical procedures, the prompt
setting up of PLACE teams, the continuing success in minimising infection (with
particularly marked improvement in catheter care and demonstrating a thorough
approach by the use of mandatory training), the changes introduced as a result of study of
patient satisfaction feedback (food and car parking), the detailed human resources
information provided, the continuing trend of success in minimising readmissions and the
improvements in the booking system.
We have a remaining slight concern at the increase in staff turnover and the increased
usage of Health Care Assistants (HCAs) perhaps at the expense of more qualified staff. We
welcome the YC’s commitment to helping improve the standard of training of HCAs but
nonetheless are concerned at the change in the balance of nursing staff that we see
throughout NHS provision.
We take the point that improvements in reporting may give rise to an apparent increase in
the incidence of trips and falls but urge that this is carefully monitored to ensure that there
isn’t a real increase in the incidence of such events. We welcome the action plan that has
been put in place to tackle this and are confident that the YC prioritise tackling such
untoward incidents.
We thought that much of the QA was admirably clear and welcome the increase in detail
provided in this year’s QA e.g. of the changes in practice following the productive ward
initiative and the explanation of the local audits carried out within the Ramsay Corporate
Programme. However, there are still places where we would welcome further information
or more clarity. For example although there was no clear trend in complaints received it
would have been helpful to have one or two further examples – it is always helpful to have
a picture of negative feedback even where this is apparently random; and we would have
liked further information about the variation in performance in the Clinical Audits set out
in Appendix 2 (e.g. comparison with previous years).
We are pleased to see that there has been an increase in the percentage of staff completing
feedback surveys and it is a positive sign that measures of pride in their workplace
amongst staff at the YC is better than the average for other heath providers asking
comparable questions however it is still disappointing that more than a third of
respondents do not express pride at working for YC.
Quality Accounts 2012/13
Page 23 of 36
Part 3: Review of quality performance 2012/2013
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 realtime 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)
Statements of quality delivery
Ramsay Clinical Governance Framework 2012/13
The aim of clinical governance is to ensure that Ramsay Yorkshire Clinic develops and
maintains ways of working which assure that the quality of patient care is central to the
business of the organisation.
The emphasis at the Yorkshire Clinic 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 at the right time.
At The Yorkshire Clinic 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. The domains of this
model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Quality Accounts 2012/13
Page 24 of 36
Ramsay Health Care Clinical Governance Framework
The Matron at the Yorkshire Clinic actively promotes clinical governance and openly
collaborates with NHS partners. This ensures that our NHS colleagues are informed of
any relevant governance concerns, incidents and any necessary actions and learning’s
as outcomes from this and additionally that the Yorkshire Clinic is informed of relevant
initiatives to continually improve the safety and excellence of the services offered.
Matron attends a number of district meetings to nurture relationships with key
stakeholders/NHS/PCTs these include – Quality Performance Group, Serious
Untoward events group, District dignity group and Controlled Medicines Local
Intelligence Network group.
The Yorkshire Clinic holds regular committee meetings where governance is a key
focus, including monthly clinical governance committee, quarterly Medical Advisory
Committee, bi-monthly Health & Safety committee.
NICE / NPSA guidance
Ramsay complies with the recommendations issued by the National Institute for Health
and Clinical Excellence (NICE) including technology appraisals in addition to Safety
Alerts issued by the National Patient Safety Agency (NPSA).
Ramsay Healthcare has a Clinical Alert System (CAS) in place to disseminate all
national clinical guidance and alerts to local Hospital level, selecting those that are
applicable to our business. The Yorkshire Clinic has a local process where guidance
and alerts reach the relevant staff members in a timely manner, and an audit trail to
evidence and act upon necessary actions and changes in practice. National guidance
such as NICE and NPSA is discussed at both clinical governance and medical advisory
committee meetings.
Quality Accounts 2012/13
Page 25 of 36
For the reporting period 241 CAS alerts were received, and were all responded to
within the required timeframe.
3.1 Patient safety
The Yorkshire Clinic is a progressive hospital focussed on improving its performance
every year, particularly with regard to patient safety.
Risks to patient safety are identified 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. To enhance our reporting
culture and awareness, and the skills of our teams to investigate and learn from safety
incidents, a specific ‘feedback forum’ was introduced in January 2013. This
encourages all our staff to focus on identifying the root cause and increases ownership
and accountability to change and improve practice through learning.
A new Mandatory Training Policy has now been launched by Ramsay as well as a
standardised induction programme. This is supported by e-learning covering vulnerable
adult training, child protection, information security, health and safety; fire; basic life
support; manual handling and infection prevention and control.
As a minimum all staff undertake annual mandatory infection prevention and control,
fire, manual handling and basic life support training, along with, our newly introduced
customer care training which came into effect during 2012.
Details of all staff training undertaken in the year are logged on to our electronic training
register. This identifies any shortfalls in an individual’s professional development which
can then be addressed.
3.1.1 Infection prevention and control
The Yorkshire Clinic has had no reported MRSA Bacteraemia; Clostridium difficile or E
coli infections in the past 6 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia, Clostridium difficile and E coli infections with a programme to reduce
incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery on hips and knees and remained as a high achiever with
minimal reported surgical site infections throughout 2012/13.
An annual strategy for Infection Prevention and Control (IPC) is developed at a
corporate level by the Group IPC and policies are revised and redeployed every two
years. IPC programmes are designed to bring about improvements in performance and
practice. These improvements can be seen in The Yorkshire Clinic IPC audit results
(page 12).
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice. Within the
Yorkshire Clinic we have infection control link nurses in all clinical areas ensuring that
IPC management remains high priority throughout the hospital.
Quality Accounts 2012/13
Page 26 of 36
The Local IPC Committee is chaired by our Consultant Microbiologist and consists of
representatives from all areas of the hospital. The committee meets quarterly to
oversee implementation of corporate policies and National guidance and review clinical
practice. Minutes from local meetings develop and review action plans to address
issues identified in both the corporate and local annual strategy/plan for infection
control. All staff undertakes mandatory IPC training annually plus the clinical staff
receive bi-annual Infection Prevention and Control training/updates from our Consultant
Microbiologist.
Healthcare associated infections (HCAI) are acquired as a result of healthcare
intervention. High standards of Infection Prevention and Control practice minimise the
risk of occurrence and as can be seen from the bar chart below. The prevalence of
healthcare-associated infections (HCAI) was 6.4% in 2011 (Health Protection Agency,
English National Point Prevalence Survey on Health-care Associated Infection, 2011)
The latest figures for The Yorkshire Clinic show an infection rate of 0.03%.
Hospital Acquired Infections
0.15%
0.10%
0.05%
0.00%
10/11
11/12
12/13
The Yorkshire Clinic
3.1.2 Cleanliness and hospital hygiene
The Yorkshire Clinic undertook a Patient Environment Action Team (PEAT) audit in
March 2012 scoring 98%, a 2% improvement on the previous year.
These assessments include rating of privacy and dignity, food and food service, access
issues such as signage, bathroom / toilet environments and overall cleanliness.
In January 2012 the Prime Minister called for new Patient Led Assessments of the Care
Environment (PLACE). These assessments will build on the foundation of PEAT audits
previously undertaken. The two main differences in the assessment is that patients
make up at least 50% of the assessment team giving them a much stronger voice.
Focus on improvement, with hospitals reporting publicly on how they plan to improve.
Ramsay Healthcare have embraced this new initiative and The Yorkshire Clinic will
undertake its first PLACE assessment in May 2013.
The graph below shows our patient satisfaction of the environment over the last 3
years. Results for 2013 will be available following the PLACE audit in May
(2013 results not available at the time of report)
Quality Accounts 2012/13
Page 27 of 36
Patient Satisfaction with
environment
100%
95%
90%
Patient Satisfaction with
environment
85%
80%
75%
2010
2011
2012
Ramsay environmental audits continue to be undertaken quarterly as per Ramsay
national audit programme and the Yorkshire Clinic has demonstrated a further 1%
improvement in the last 12 months. The hospital wide cleaning matrix has been
utilised, informing staff what needs cleaning, with what, when and by whom.
The decline in the general environment audit percentage is due to Xxxxxxx and
AUDIT
STANDARD
Management
General
Environment
Clinical
Equipment
Decontamination
Clinical Practice
Sharps Handling
& Disposal
Waste Disposal
Hand Washing
%
Compliance
May 2012
%
Compliance
August 2012
100
94
%
Compliance
November
2012
100
95
%
Compliance
February
2013
100
96
100
96
100
100
100
100
100
100
82
100
100
82
100
100
82
100
100
91
100
100
100
94
100
100
100
100
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, The Yorkshire Clinic member of staff have a high awareness of safety and
are the foundation for our overall corporate risk management programme. This
awareness naturally extends to safeguarding our patients.
Effective and on-going communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every month
and these are issued to all relevant staff as soon as received via an electronic system
called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls
Quality Accounts 2012/13
Page 28 of 36
and new and revised policies are cascaded in this way to our General Managers who
ensure we keep up to date with all safety issues. Evidence of necessary actions and
changes in practice are monitored and recorded for each and every alert received.
Adverse Incidents reported at the Yorkshire Clinic affecting patients, visitors, staff and
sub-contractors were:
2010/11 - 103
2011/12 - 122
2012/13 - 278
Adverse incidents reported are comparative with the numbers of patients, visitors, staff,
sub-contractors who utilise the Yorkshire Clinic every year. The above figures show an
increase in incident reporting via our RISKMAN reporting system which reflects a raised
awareness and improved reporting of actual incidents and near misses, indicating the
importance of safety in the workplace. All incidents reported are investigated and action
plans formulated to address any issues.
3.2 Clinical effectiveness
The Yorkshire Clinic 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. Incident and near-miss reporting is
encouraged to ensure effective learning in a no blame culture.
3.2.2 Readmission to hospital
Monitoring rates of re-admission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due to
sound clinical practice ensuring patients are not discharged home too early after
treatment and are independently mobile, not in severe pain etc.
40
Readmissions
20
0
10/11
11/12
The Yorkshire Clinic
12/13
As can be seen in the above graphs our readmission to hospital rate has changed little
over the last 2 years. These figures are constantly monitored throughout the year via
our clinical governance and medical advisory committee framework.
Quality Accounts 2012/13
Page 29 of 36
3.3 Patient experience
Feedback from patients regarding their experience at The Yorkshire Clinic is
encouraged and is essential to inform our staff how care can be enhanced or adjusted
to meet individual patient satisfaction.
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 on notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative comments or suggestions for improvement are also communicated 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. Every complaint received
is given immediate attention of the General Manager and Matron on the day it is
received, following which a thorough investigation is commenced into the concerns
raised as per Ramsay Complaints Policy.
Patient experiences are received from the various routes listed below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis and
further actions as necessary. Escalation and further reporting to the Ramsay Corporate
Governance Team, our stakeholders and regulatory bodies occurs as required in line
with Ramsay Healthcare and Department of Health policy.
Feedback regarding the patient’s experience is received through the following routes:
Patient satisfaction surveys
We value your opinion’ leaflet
Direct verbal feedback to Ramsay staff.
Internal Ramsay audit /inspection processes.
CQC inspection feedback.
Written feedback via letters/emails/complaints
Patient focus groups
PROMs surveys
Care pathways – patients are encouraged to read and participate in
their plan of care.
3.3.1 Patient Satisfaction Surveys
As an organisation we pride ourselves on ensuring patients are informed of decisions
and why they have been made (including discussions around what will happen, in
terms of procedures etc) at every stage of their care pathway and this is evidenced in
the feedback results we have received back from patients.
Before the operation or procedure, did a member of staff explain the risk and
benefits in a way you could understand? (98% of patients agreed)
Were you involved as much as you wanted to be in decisions about your care
and treatment? (99% of patients agreed)
Sufficient involvement in discussions about treatment (99% of patients
agreed)
Quality Accounts 2012/13
Page 30 of 36
Given written post-discharge advice about how to look after yourself at home
(95% of patients agreed)
3.3.2 Patient Reported Outcome Measures (PROMs)
The Yorkshire Clinic hospital participates in the Department of Health’s PROMs
surveys for hip and knee surgery, hernias and varicose veins for NHS patients.
Compliance for PROMs is above the national average at The Yorkshire Clinic. The
health gain score figure is the difference between the pre-operative and post operative
survey scores.
Average health gain
EQ-5D VAS - casemix adjusted
Groin Hernia
0
-0.2
England
THE YORKSHIRE
CLINIC
-0.4
-0.6
-0.8
Adjusted average health
gain
Oxford Hip Score
40
20
0
England
THE YORKSHIRE
CLINIC
Access to the Yorkshire Clinic and Ramsay PROMs results can be found at the
following website:
http://www.yhpho.org.uk/resource/view.aspx?RID=64442
3.4 The Yorkshire Clinic Hospital Case Study
In 2012 a full review of the Cardiology services was undertaken at the Yorkshire Clinic
,this review was for both Cardiac Angiography and Cardiology OPD Diagnostic
services. A specialist Cardiology Manager was brought in to review; develop and
improve the service. The review found that not all Cardiology diagnostic services were
available at The Yorkshire Clinic and the service was further restricted due to staffing
issues resulting in unacceptable waiting times for patients who required Cardiology
investigations.
Quality Accounts 2012/13
Page 31 of 36
In order to meet the guidelines for British Cardiac Society more Cardiac Physiologists
have been recruited to both contracted and bank staff this now enables us to provide
patients with a service which is accessible both during the day and evening.
Full review of the service offered found that further training was required for our Enquiry
Team regarding Cardiology appointments, this was monitored by the Support Services
Manager and recruitment of a full time secretary now makes it much easier for patients
to book appointments at any time of the day.
New ‘diagnostic’ only clinics have been introduced so that secretaries can book
patients straight on to our electronic booking system. Any patients who have to wait
more than two weeks for an appointment are contacted to offer them the option of
moving to another consultant.
Equipment has been purchased by the Yorkshire Clinic and by following evidence
based protocols we are able to ensure a seamless; timely; good quality service for our
patients. As a result of the review undertaken we are now able to offer the following
extra Cardiology Services: Stress Echo
Cardiac MRI & Respiratory function (planned to commence 2013).
Quality Accounts 2012/13
Page 32 of 36
Appendix 1
Services offered by The Yorkshire Clinic



































Anaesthetics
Audiology
Bariatrics
Cardiology
Cosmetic
Dermatology
Dietetics
Endocrinology
ENT
Gastroenterology
General Medicine
General Surgery
Gynaecology
Haematology
Nephrology
Neurology
Neurophysiology
Oncology
Ophthalmology
Oral Surgery / Restorative Dentistry
Oral and Maxillo Facial
Orthopaedics
Orthotics
Paediatrics
Pain Management
Pathology
Psychology
Radiology
Respiratory Medicine
Rheumatology
Sleep Studies
Speech Therapy
Urology
Vascular
Venerology
Quality Accounts 2012/13
Page 33 of 36
Appendix 2 – Clinical Audit Programme
Audit Programme v5.0 2012/13
Hospital Name: The Yorkshire Clinic
Authors: R. Saunders / A. Shannon / N. Carre
Implemented: July 2012
For review: June 2013
Use arrow symbol to locate required audit
JUL
Anaesthetic Standards
Medical Records
AUG
OCT
NOV
94%
95%
92%
95%
90%
69%
FEB
98%
75%
84%
MAR
APR
MAY
90%
91%
70%
70%
98%
72%
98%
86%
96%
Prescribing
100%
92%
Medicines Management
88%
85%
Radiology
Physiotherapy
95%
100%
90
98%
100%
100%
92%
100%
97%
Theatre
Transfusion
80%
99%
Controlled Drugs
Infection Prevention and
Control - Environmental Audit
JAN
89%
Care Pathways and Variance
Tracking
Infection Prevention and
Control*
DEC
92%
Consent
Discharge
SEP
93%
100%
100%
100%
n/a
99%
99%
94%
SSI
95%
90%
100%
100%
100%
96%
N/A
100%
90%
98%
A llo geneic
Quality Accounts
2012/13
Traceability
Page 34 of 36
Appendix 3
GLOSSARY OF ABBREVIATIONS
ANTT
Aseptic Non Touch Technique
BADS
British Association Day Care Surgery
CAS
Central Alert System
CQC
Care Quality Commission
CQUINS
Commissioning for Quality and Innovation
EMSA
Eliminating Mixed Sex Accommodation
GRSA
Global Rating Score
HCA
Health Care Assistant
HCAI
Health Care Associated Infection
IPC
Infection Prevention and Control
ISB
Information Standards Board
JAG
Joint Advisory Group
MEWS
Medical Early Warning System
MHRA
Medicines & Healthcare Products Regulatory Agency
MRSA
Methicillin-resistant Staphylococcus Aureus
NICE
National Institute for Clinical Excellence
NJR
National Joint Registry
NPSA
National Patient Safety Agency
OPD
Out Patient Department
PEAT
Patient Environment Action Team
POA
Pre-Operative Assessment
PROMS
Patient Reported Outcome Studies
PW
Productive Ward
RIDDOR
Reporting of Injuries, Diseases and Dangerous Occurrences. Regulations.
RIMS
Risk Information Management System
SHA
Strategic Health Authority
SLA
Service Level Agreement
TLF
The Leadership Factor
VTE
Venous Thromboembolism
WHO
World Health Organisation
Quality Accounts 2012/13
Page 35 of 36
The Yorkshire Clinic
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:
01274 550673
Email Carina.gundill@ramsayhealth.co.uk
Neurological Centres
Quality Accounts 2012/13
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