Woodland Hospital
Quality Account
2012/13
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Woodland Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager – Tania Terblanche
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)
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2
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
Quality Accounts 2012/13
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Welcome to Ramsay Health Care UK
Woodland 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, CCGs 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 Woodland Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our achievements
in terms of clinical excellence, effectiveness, safety and patient experience and
demonstrates that our managers, clinicians and staff are all committed to providing
continuous, evidence based, quality care to those people we treat. It will also show that
we regularly scrutinise every service we provide with a view to improving it and
ensuring that our patients’ treatment outcomes are the best they can be. It will give a
balanced view of what we are good at and what we need to improve on.
The first Quality Account for 2009/10 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 will develop its own Quality Account yearly, which
will include some Group wide initiatives, but will also describe the many excellent local
achievements and quality plans that we would like to share.
Quality Accounts 2012/13
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Part 1
Tania Terblanche General Manager,
Woodland Hospital
Our Vision; “We are here to deliver the highest standards of care and service to our
patients. We will do this as a professional and committed team.”
Woodland Hospital is a major healthcare provider in the Kettering area. The hospital
was established 24 years ago and is part of Ramsay Health Care, an international
Healthcare provider.
We are passionate about healthcare. We are professional and committed. We have
extensive outpatient and inpatient facilities delivering the highest standards of care and
services to our patients. During the last 16 months, the Hospital underwent a significant
redevelopment. This allows us to offer even better facilities with greater access to more
patient services.
We provide a wide range of services to insured, self pay and NHS patients. We have
agreements in place with national insurance companies and also hold a contract with
the CCGs (Clinical Commissioning Groups previously known as PCTs).
We have a strong track record as a safe and responsible provider. Our outcomes are
shared with our private and NHS contractors through regular reporting and audit
programmes. Our latest CQC visit confirmed that patient care and hospital standards
exceed patient and stakeholder expectations. Excellent patient feedback experience is
also reflected in our patient satisfaction survey results.
At Woodland Hospital we believe that all staff play a part in the success of the hospital.
The Senior Management Team work closely with all staff and our stakeholders to
ensure we work in partnership to improve and develop services and processes. All staff
receive regular training to facilitate their own professional development and this is
managed through our training matrix. It is structured to complement the skills and
experience of each individual. This helps us ensure the training supports the
consistently high standards the hospital has set itself.
The quality account gives all parties and providers access to the Woodland Hospital
patient treatment outcomes. If you would like to comment or provide me with feedback
then please feel free to contact me.
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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.
Tania Terblanche
General Manager
Woodland Hospital
Ramsay Health Care UK
Email: tania.terblanche@ramsayhealth.co.uk or Tel: 01536 414 515.
This report has been produced by:
Tania Terblanche – General Manager
Elaine Rowland – Matron
Lorna Dodwell – Regional Business Development Manager, Midlands Region
Caroline Derby – Finance Manager
Jeff Hickson – Support Services Manager
This report has been reviewed and approved by:
Date
Name
Role
Mr R Haughney
MAC Chair
Mr J Szafranski
CGC Chair
Mr J Beech
Regional Director
Mrs E Clarke
Quality Development
Lead - CCG
E-Signature
Woodland Hospital Management Team work in partnership with the MAC and the CGC
Committee, ensuring that high quality patient care is at the centre of what we do.
Regular meetings with the above Committees ensure best practice and result sharing.
Quality Accounts 2012/13
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Welcome to Woodland Hospital
The Woodland Hospital, named after the famous local Woodland Pytchley Hunt, was
originally built in 1989 and was designed to combine modern technology with the
highest standard of patient care and comfort. Our staff are carefully selected for their
friendly and caring approach as well as their efficiency and professionalism and a
Resident Doctor is available 24 hours a day. The restful atmosphere and high level of
personal attention combine to help patient recovery. The first patients were admitted in
June 1990 and the hospital has continued to grow and develop since this date.
Since 1996 the hospital has continued to expand and now comprises of three laminar
flow theatres making them ideal for orthopaedic surgery and reducing the risk of
infection in any patients due to the air filters and air changes. The hospital has recently
opened a modern ambulatory (day case unit) and has refurbished many of its facilities
including the high dependency unit, patient bedrooms, endoscopy and recovery suites
and outpatient rooms. Our clinical areas boast state of the art monitoring systems and
equipment ensuring our patients receive safe care using modern technology.
To meet the growing needs of the business the Woodland Hospital provides
convenient, effective high quality treatment for patients of all ages on an inpatient and
outpatient basis (excluding children below the age of 3 years for inpatient activity),
whether medically insured, self-pay or from the NHS. From April 2012 to March 2013
we treated a total of 6768 admissions, with 62.1% being NHS patients.
The Hospital provides a comprehensive range of services that are listed in Appendix 1,
and these include Medical, Orthopaedic, Surgical, Ophthalmology, Ear, Nose and
Throat, Urology, Gynaecology, Maxillofacial and Cosmetic services. The Hospital also
provides a range of routine and complex spinal services.
To ensure that patients are at the centre of everything we do and receive the highest
standard of care, we have 147 dedicated Consultants, working alongside 89 nursing,
radiology, physiotherapy and pharmacy staff, together with 59 administration,
housekeeping, maintenance and catering staff.
At the Woodland Hospital we work closely with our colleagues at the local Trusts and
CCG (Clinical Commissioning Group) to ensure our services meet the needs of the
patients we serve, including shared training and development programmes, infection
control and pathology services.
It is also key that we support people and services within the community and charities by
selecting a charity of the year, over £2,711 was raised in 2012/13 for Guide Dogs for
the Blind.
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Part 2
2.1 Quality priorities for 2012/13
Plan for 2012/13
On an annual cycle, Woodland 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 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 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 2012/13 (looking back)
•
Introduction of the National Patient Safety Thermometer
The National Patient Safety Thermometer is a national initiative which allowed us
to monitor the level of harm our patients may be exposed to. The monitoring took
place on a pre-determined date each month and was applicable to all inpatients
on that set date. Data was entered on a template and was submitted directly to
the Department of Health Information Centre to monitor the incidence of falls,
VTE assessment and preventative treatment, and urinary infections. Through
submitting this data on a monthly basis, we were able to benchmark ourselves
against other Hospitals within Ramsay Health Care and within the NHS. This
monitoring enabled the Woodland Hospital to demonstrate that throughout the
year we did not expose our patients to any harm.
•
Implementation of Risk Man
In 2012/13 a new incident reporting system was launched which allowed greater
accuracy in recording incidents and supported enhanced data and trend
analysis. This supported our patient safety ethos.
Quality Accounts 2012/13
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•
Implementation of Electronic Rostering System
In order to support the monitoring of staffing levels and skill mix, a new electronic
rostering system was planned to be implemented across all departments in
2012/13, this has been delayed until 2013/14 for Woodland Hospital.
•
Increased Patient Feedback Systems
To ensure our services meet our patients expectations we implemented a new
system of gaining feedback on our patients experience which complemented our
existing system. We used an external company to obtain our patient feedback;
this ensured the results were completely unbiased and independent. In
conjunction with this, patients were actively encouraged to complete the ‘We
Value Your Opinion’ feedback forms and a member of the senior management
team replied to each completed form. A summary of our feedback systems is
demonstrated in section 3 of this report.
2.1.2 Clinical Priorities for 2013/14 (looking forward)
•
Implementation of Electronic Rostering System
To support the monitoring of staffing levels and skill mix, a new electronic
rostering system will be implemented across all departments in 2013/14.
•
Gain JAG accreditation
JAG Accreditation intends to stimulate continuous improvement in processes and
patient outcomes through assessment of staff competency, provision of best
practice through comparisons with other sites, improve management and
efficiency of service and increase patient confidence in service delivery.
•
Undertake PLACE assessment
The recent Francis report highlights the importance of peer review and concludes
that it should form an essential part of practice across all providers of NHS
funded care. This is more specifically reflected in recommendation 101 of the
main report which recommends the organisation of 'mutual peer review
inspections or the inclusion in the Patient Environment Action Team (PEAT) of
representatives from outside the organisation'. Patient Led Assessment of
Clinical Environment (PLACE) assessment is a patient led assessment focusing
on four areas, cleanliness, catering, environment and facilities. The CQC are
made aware of the results of these assessments as they directly impact on the
delivery of patient services.
• Ensure compassionate Care Delivery as outlined in the Chief Nursing
Officer’s ‘Compassionate Care strategy’
It is essential that our patients receive the very best care with compassion and
clinical skill, ensuring we have pride in our services and profession. The
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underpinning values of care delivery is ensuring it is the core value of the
organisation, delivered with compassion and empathy by competent staff,
communicated to all patient users and employees and we have the courage to
identify when we fall below the expected standard and have the commitment to
improve the care and experience of our patients. These values will be our
philosophy of care and promise to our patients.
• Improve information provided to patients post operatively, including
medication advice, as outlined in the NHS survey 2012/13
Communication is central to providing successful care and effective partnership
working. Through our recent NHS inpatient survey, a recommendation was to
improve our information provided to patients, and we need to strengthen our
involvement of our pharmacy team in pre operative and post operative care.
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 Woodland Hospital provided and/or subcontracted over 22 NHS
services.
The Woodland Hospital has reviewed all the data available to them on the quality of
care in all of these NHS services.
The income generated by the NHS services reviewed in 1st April 2012 to 31st March
2013 represents 37% of the total income generated from the provision of NHS services
by the Woodland 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 included:
Human Resources
•
•
•
HCA Hours as % of Total Nursing
Agency Hours as % of Total Hours
% Staff Turnover
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•
•
•
•
•
•
% Sickness
Total Lost Worked Days
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
•
•
•
•
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
Quality
•
•
•
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
2.2.2 Participation in clinical audit
The national clinical audits that Woodland Hospital participated in during 1st April 2012
to 31st March 2013 are as follows:
Elective procedures
•
•
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Blood transfusion
• O negative blood use (National Comparative Audit of Blood Transfusion)
The data relating to these audits are listed below alongside the number of cases
submitted to each audit as a percentage of the number of registered cases required by
the terms of that audit.
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National Clinical Audits
Name of Audit
Participation
Peri-and Neo-natal
N/A – no service
Insufficient Patient
Numbers
N/A – No Service
Insufficient Patient
Numbers
Children
Acute care
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Cardiovascular disease
Renal disease
Yes
Yes
N/A – No service
N/A – No service N/A – No service Cancer
Trauma
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Health promotion
End of life
N/A – No service N/A – No service YES
N/A – No service N/A – No service Local Audits
From 1st April 2012 to 31st March 2013 a robust clinical audit calendar was in place and
thought the year 58 audits were undertaken, including: 12 infection prevention and
control, 3 transfusion, 4 physiotherapy and 7 radiology audits. The results were
reviewed at a local level and nationally by the Clinical Governance Committee. The
main area that was identified as requiring action to improve the quality of healthcare
provided are as follows:
•
•
•
•
Nutrition and hydration – specifically completing fluid balance charts
The process of consent
Correct calculation of EWS (Early Warning System)
Medicine’s Management
These have been the key focus of the Clinical Governance Committee throughout the
year and actions have been implemented at department level and although the results
have already improved the areas will continue to be a key focus in 2013/14. The
clinical audit schedule can be found in Appendix 2.
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• Consent
At Woodland Hospital, consent is gained in a two stage process; stage one being taken
by the Consultant, and second stage being taken on admission by the nurse, who
confirms that the patient fully understands all aspects of consent. The area of
improvement is first stage consent, many Consultants explaining the details of the
operation at the outpatient appointment and then taking written consent by the patient
on admission. This has been raised at the MAC meeting, and the Consultants have
agreed to provide a copy of the clinic letter, confirming what procedure was discussed
with the patient, so this may be filed in the patient’s medical records.
2.2.3 Participation in Research
There were no patients recruited during 2012/13 to participate in research approved by
a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The following CQUIN’s were allocated to the Woodland Hospital in 2012/13.
Indicator name
VTE risk
assessments of
admitted patients
NHS
Thermometer
Patient
experience
Descriptor
Plan/Weighting
% of all adult inpatients who have had a VTE risk
assessment on admission to hospital using the clinical
criteria of the national tool
90% of all high risk patients receive appropriate
treatment
90%
90%
Monthly surveying all appropriate patients (as defined in
the NHS Safety Thermometer guidance) to collect data
on four outcomes (pressure ulcers, falls, urinary tract
infection in patients with catheters and VTE).
Monthly
submission
To establish question and baseline Net Promoter Score
for 10% of inpatients
0.25%
Quarterly report to board and commissioner at hospital
0.25%
Achieve a 10 point improvement in Net Promoter Score
of achieve or maintain top quartile performance (targets
and top quartile will be calculated using Q1 baseline
data)
0.5%
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2.2.5 Statements from the Care Quality Commission (CQC)
Woodland Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions.
The Care Quality Commission carried out an unannounced inspection of Woodland
Hospital in March 2013 and the hospital met all the requirements of the standards
reviewed at this inspection. The full report is available on the CQC website via the link
below.
http://www.cqc.org.uk/public/reports-surveys-and-reviews
2.2.6 Data Quality Statements
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2010/11 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 included:
The patient’s valid NHS number:
•
•
•
99.98% for admitted patient care;
99.95% for outpatient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
The General Medical Practice Code:
•
•
•
99.99% for admitted patient care;
99.99% for outpatient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
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/
Clinical coding error rate
Woodland hospital was not subject to the Payment by Results clinical coding audit
during 2012/13 by the Audit Commission.
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2.2.7 Stakeholders views on 2012/13 Quality Account
To support our Quality Account we sent a copy to Corby Clinical Commissioning Group
and Nene Clinical Commissioning Group. The report underwent a detailed review by
these groups. Peter Boylan, Director of Nursing and Quality responded with the
following information:
“ Woodland Hospital (Ramsay Group) annual quality account for 2012-13 has been
reviewed. Nationally mandated elements are included in the report together with
internal and external assurance mechanisms for quality being used. The report
contains accurate data.
Achievement against the quality indicators including CQUIN schemes outlined in the
report is noted with the positive effect this has had on patient care.
Nene & Corby Clinical Commissioning Groups (N&C CCG), wholly support the 2013-14
quality priorities as set by the Woodland in relation to improving patient safety, clinical
effectiveness and patient experience.
Commissioners will continue to work closely with the Hospital and support ambitions to
sustain high quality standards of care for people who use services via incentivising
quality improvements, quality review assessments and performance management”
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Part 3: Review of Quality
Performance 2012/2013
Statements of Quality Delivery
Matron, Elaine Rowland
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 2012/13
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
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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
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).
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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 focussed on continually improving our performance
every year and in all performance respects. Particular emphasis is placed on our
patient safety track record.
Patient safety is monitored through routine audit, adverse incident reporting and patient
feedback, identifying trends in performance indicators as illustrated in the graphs
included in the report.
3.1.1 Infection prevention and control
Woodland Hospital has a very low rate of hospital acquired infection and has had
no reported MRSA Bacteraemia, MSSA Bacteraemia or Clostridium Difficile
Infections in the past 3 years.
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.
Programmes and activities within our hospital include:
•
Local quarterly infection control meetings and twice yearly Infection Control
Committee meetings with the local Trust.
•
Lead Consultant involved in infection control providing links with Consultant
colleagues.
•
Monthly report on all aspects of infection control to Heads of Departments.
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Hospital Acquired Infections 2 1 0 10/11 11/12 12/13 Woodland Hospital •
Over the last three years our infection rate has remained very low. These
excellent infection rates are due to robust pre-admission processes and infection
control practices, with hand hygiene being a primary focus point for all staff
working at the Hospital.
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits. These assessments include rating of privacy and
dignity, food and food service, access issues such as signage, bathroom / toilet
environments and overall cleanliness. The table below demonstrates our results.
Environment
Food
Privacy and Dignity
2010/11
Excellent
Excellent
Good
2011/12
Good
Good
Excellent
2012/13
Good
Good
Excellent
In conjunction with these assessments, we also participated in the national NHS patient
survey. The results demonstrated that:
•
•
•
•
•
Over 90% of patients described the cleanliness of the hospital as very clean
96% of our patients thought our toilets and bathroom’s were clean
98% of our patient’s felt that there were enough hand gels available for patients
and visitors
80% of our patients were happy with the food provided to them and were offered
choice in relation to the food provided
100% of patient’s felt that their dignity was maintained during examination and
discussing their treatment
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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. Effective and
ongoing communication of key safety messages is important in healthcare. Multiple
updates relating to drugs and equipment are received every month and these are sent
in a timely way via an electronic system called the Ramsay Central Alert System (CAS).
Safety alerts, medicine / device recalls and new and revised policies are cascaded in
this way to our General Manager, which ensures we keep up to date with all safety
issues.
Any incident that occurs is reported through incident reporting and these are discussed
at our Medical Advisory Committee, Clinical Governance and Health and Safety
meetings. We analyse these incidents for trends and themes and take action where
indicated. The graph below identifies the number of untoward incidents reported per
year over the past three years.
All Incidents 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% 10/11 11/12 12/13 Woodland Hospital The above graph appears to show we have had an increase in our incidents; however,
since Riskman (our incident reporting system) was introduced we are able to record
incidents more accurately and comprehensively than our previous incident reporting
system allowed.
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3.1.4 Caring for patient’s privacy and dignity – same sex
accommodation
At Woodland Hospital we are committed to making sure that all our patients receive
high-quality care that is safe and effective.
Our patients have the right to privacy and to be treated with dignity and respect. We
believe that providing same-sex accommodation is a key part of achieving this and
allows us to give all of our patients the best possible experience while they are in
hospital.
We have the necessary facilities, resources and culture to ensure that patients who are
admitted to our hospitals will only share the room where they sleep with members of the
same sex, and same-sex toilets and bathrooms will be close to their bed area.
Sometimes the need for effective treatment is greater than the need to provide samesex accommodation. This might happen if patients need urgent, highly specialised or
high-tech care, for example high-dependency care. On these occasions, it is acceptable
for men and women to be treated together; this will be based on very specific medical
requirements.
3.1.5 Caring for your privacy – data protection
Doctors and other health professionals caring for patients keep records relating to
patient’s health, treatment and care delivered at the Woodland Hospital. These help us
to ensure that patients receive the best possible care. These records may be written
down or held on a computer and are used to guide and administer the care patients
receive to ensure full information is available to anyone involved in delivering safe care.
Everyone working at Woodland Hospital has a legal duty to keep information about
patients safe and confidential. If patients receive care at another organisation and they
need access to the records held at the Woodland Hospital, there is a strict process that
must be followed. That normally involves us obtaining patient consent prior to
disclosing any information. There are times when we are required by law to pass on
information to the appropriate authorities but this is only done after formal permission
has been given by a qualified health professional. Anyone who receives information
from us is also under a legal duty to keep it confidential.
3.2 Clinical effectiveness
Woodland 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 the Medical Advisory
Quality Accounts 2012/13
Page 21 of 29
Committee to ensure results are visible and tied into actions required by the
organisation as a whole.
The results highlighted in the graphs demonstrate the effectiveness of this approach
over the last three years.
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 return 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.
Reoperations 0.20% 0.15% 0.10% 0.05% 0.00% 10/11 11/12 12/13 Woodland Hospital •
•
As can be seen in the above graph our return to theatre rate is very low and as
we are performing increased complex surgery we need to monitor and review the
rates of patients returning to theatre. When considered as a percentage of the
total patients undergoing surgery the return to theatre rate was 0.16% for
2011/12 and is 0.10% for 2012/13.
Each patient that is returned to theatre has a full review of the records and the
findings discussed at the Medical Advisory Committee, with an action plan
implemented and monitored if indicated
Quality Accounts 2012/13
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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 etc.
Readmissions 15 10 5 0 10/11 11/12 12/13 Woodland Hospital •
•
As can be seen in the above graph our readmission to hospital rate has
decreased in 2012/13 and remains very low.
Every readmission is fully reviewed to identify the causative factor for the
readmission and these are discussed and practice changed if required.
3.2.3 Transfers
Monitoring rates of transfers out of the Hospital is another valuable measure of clinical
effectiveness. As with any incident, transfers are reviewed and analysed to identify any
emerging trend with specific surgical operation or surgical team in common and may
identify contributory factors needing to be addressed.
Transfers 10 5 0 10/11 11/12 12/13 Woodland Hospital Quality Accounts 2012/13
Page 23 of 29
•
•
As can be seen in the above graph our transfer out of the hospital has increased
in 2012/13, but when considered as a percentage of the total patients
undergoing surgery the transfer rate was 0.13% for 2012/13.
Every transfer is fully reviewed to identify the causative factor for the transfer and
these are discussed and practice changed if required.
3.2.4 Falls
Monitoring patient falls in the Hospital is a key measure of patient safety, and each fall
is reviewed to identify any cause or theme. An example of analysing falls, in 2011/12
we had a number of patient falls and a theme identified was the type of pain killer they
were given post operatively. This was discussed with the anaesthetists and a change
was made to prescribing types and times of pain killers and the falls reduced. This
demonstrates how we use incident analysis to influence and change practice.
Falls 15 10 5 0 10/11 11/12 12/13 Woodland Hospital 3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care is
welcomed and informs service development in various ways, dependent on the type of
experience (both positive and negative) and action required to address it.
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 relayed 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.
Quality Accounts 2012/13
Page 24 of 29
Patient experiences are fed back via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay Corporate
and DH bodies occurs as required and according to Ramsay and DH policy.
Feedback regarding the patient’s experience is encouraged in various ways via:







Patient satisfaction surveys
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
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
Our patient satisfaction surveys were managed in 2012/13 by an independent company
called ‘The Leadership Factor‘(TLF). They print and supply a set number of
questionnaire packs to our Hospital each quarter, which contain a self addressed
envelope addressed directly to TLF, for each patient to use. Results are produced
quarterly (the data is shown as an overall figure but also separately for NHS and private
patients). The results are available for patients to view on our website.
From July 2012 we also requested patients to identify if they would recommend our
hospital to friends or family and the table below identified that the majority of patient
would recommend our hospital.
July
Aug
Sept
Oct
Nov
Dec
Jan
13
Fe
b
Mar
Number of NHS patients
discharged
332
371
325
380
377
295
356
34
2
373
Number of NHS patients returned
survey
275
232
206
253
282
222
258
24
3
262
Percentage of responses
82.8
%
62.5
%
67.5
%
66.5
%
74.8
%
75.2
%
72.5
%
71
%
70.2
%
In 2012/13 Ramsay hospitals participated in the survey of in-patients discharged from
Ramsay Health Care UK hospitals between January and August 2012. The survey used
the same methodology, questionnaire and timetable as the CQC national patient survey
required of all NHS Trusts. Overall 13,247 patients were included from 24 Ramsay
hospitals with 9,588 responding (73%), this is a very high response rate. For Woodland
Hospital 603 patients were mailed a questionnaire with 423 returned, a response rate of
71%.
Quality Accounts 2012/13
Page 25 of 29
Overall, the survey demonstrated that Woodland Hospital provided a very high level of
patient care, and scored 90% or over positive in the following areas:
•
•
•
•
•
•
•
•
•
•
•
Waiting times
Single sex accommodation and bathrooms
Cleanliness
Food
Communication with nurses and doctors
Privacy
Pain management
Information about surgery
Discharge Planning and information
Overall rating of care
Being treated with dignity and respect
The only area identified for improvement is to ensure patients receive a copy of letters
sent to their GP’s and this will be a focus for 2013/14.
3.4 Woodland Hospital Case Study
Introduction of Joint School for Patients undergoing Primary Hip and Knee
Replacement Surgery
We have provided joint replacement surgery at the Woodland Hospital since opening in
1989, with physiotherapy pre-surgery being delivered on a one to one basis. In
2012/13 to improve the outcome for patients, reduce length of stay and enhance the
recovery process the hospital took a unique and proactive approach to the care,
recovery and rehabilitation of its joint replacement patients and introduced a joint school
for any patient undergoing primary joint replacement surgery. The patient and the
various health care professionals will equally share the responsibility for their care and
this begins with patients attending joint school prior to admission for surgery.
Joint Replacement School is a patient education session, where the whole patient
journey is explained, questions answered and any anxieties relieved. The Joint
Replacement School ensures that patients receive optimal education and clear
expectations, which results in the best possible outcome. It provides an opportunity to
meet other patients going through the same experience.
Since its introduction, many patients have reported that they feel ‘empowered’ to
manage their recovery, understand what will be happening to them on a day by day
basis and feel prepared for the post-operative period. As a result, patients are admitted
on the day of surgery and spend three nights in hospital, where previously patients
stayed in for up to six nights, mobilise early and report less complications, such as
stiffness, pain, thrombosis and infection.
Quality Accounts 2012/13
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Appendix 1
Inpatient and Outpatient Services covered
by this quality account
Breast care
Dermatology
Ear, Nose and Throat (ENT)
Gastroenterology
General Medicine
General Surgery
Gynaecology
Ophthalmology
Oral Maxillo Facial
Orthopaedic
Pain Management
Podiatry
Physiotherapy
Medical Loans
Rheumatology
Urology
Vascular
Diagnostics
Quality Accounts 2012/13
Page 27 of 29
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Woodland 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
Tania Terblanche, General Manager using the contact details below.
Tania Terblanche
General Manager
Woodland Hospital
Rothwell Road
Kettering
NN16 8XF
For further information please contact:
Phone: 01536 414515
E-Mail:tania.terblanche@ramsayhealth.co.uk
www.woodlandhospital.co.uk