Bodmin NHS Treatment Centre
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
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 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (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 2014/15 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Bodmin NHS Treatment Centre 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 31 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, Clinical Commissioning Group.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high
quality patient care is our number one goal. This relies not only on excellent medical and
clinical leadership in our hospitals but also upon an organisation wide commitment to
drive year on year improvement in patient satisfaction and clinical outcomes.
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. It is essential that we establish an organisational culture that puts the
patient at the centre of everything we do and 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.
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 2013/14
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Introduction to our Quality Account
This Quality Account is Bodmin NHS Treatment Centre 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.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in
depth information for the public and commissioners about the quality of services within
each individual hospital and how this relates to the local community it serves.
Therefore, each site within the Ramsay Group now develops its own Quality Account,
which includes some Group wide initiatives, but also describes the many excellent local
achievements and quality plans that we would like to share.
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Part 1
1.1 Statement on Quality from the General Manager
Kathie Rimmer, General Manager
Bodmin NHS Treatment Centre
The Bodmin NHS Treatment Centre has been delivering high quality clinical services to
local residents for more than 8 years and as General Manager I take great pride in the
service we offer our patients.
This quality account has been produced to provide information about how we monitor
and evaluate the quality of the services we deliver. It has been prepared in collaboration
with every profession engaged in service provision within the hospital. Every individual
member of staff is crucial to the success of our Treatment Centre and we value the
contribution that they make in delivering great customer care.
Our vision for our hospital includes a commitment to deliver health services needed by
the local population within the scope of safe clinical practice. It also encompasses a
commitment to deliver a patient experience that will leave every patient feeling that
everything that should have been done was done to the standard they would expect.
The following pages set out our quality assurance policies and underline our
commitment to delivering the highest possible standard of service in every
circumstance.
Bodmin NHS Treatment Centre has a very strong track record as a safe and responsible
provider of healthcare and we are proud to share our results.
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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
Kathie Rimmer
General Manage
Bodmin NHS Treatment Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Peter Callen MAC Chair
Dr Marek Woyton Clinical Governance Committee Chair
Helen White Regional Director, Ramsay Health Care UK
Steven Locke Head of Commissioning Kernow Clinical Commissioning Group
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Welcome to Bodmin NHS Treatment Centre
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Bodmin NHS Treatment Centre is a purpose built day unit built in 2005 to work in
partnership with the NHS. It is equipped with 2 Theatres and a designated
Endoscopy suite.
The Treatment Centre provides NHS services throughout Cornwall and Devon. We
provide fast, convenient, effective and high quality treatment for patients above the
age of 18 with the exception of Termination of Pregnancy patients who can access
our services from the age of 16.
Bodmin NHS Treatment Centre’s services include the specialities; dermatology, ear,
nose & throat (ENT), endoscopy, general surgery, gynaecological, ophthalmic,
maxillofacial/oral, urology and orthopaedics.
We have 2 outreach clinics at Penzance and Bude.
Total number of patient admissions in the past year was almost 5000
Our clinical facilities are continually monitored to ensure that we are offering the
very best service to our patients.
We employ 39 Staff; 3 Employed Doctors, 14 Trained Nurses, one of which also fulfils
the role of Cosmetic Nurse, 6 Healthcare assistants, 4 Housekeepers, 2 Counsellors,
1.5 Stores persons and 9 Admin staff. We also share an Accountant and Engineer
with the Duchy hospital.
We have 21 Consultants with Practising Privileges, 6 with Medical Service
Agreements including 4 Ophthalmic Surgeons.
We receive our referrals from both the Kernow Referral Management Service and
the Devon Referral Support Service.
Mrs Miranda Field is our GP liaison manager. Miranda has close contact with both
the practice managers and the GPs at our practices throughout Cornwall. Miranda
organises regular “Lunch and Learns”, visiting GP surgeries to offer training and latest
development awareness as well as running evening GP training seminars on a regular
basis.
We work closely with the Royal Cornwall Hospital Treliske who provide us with blood
transfusion, histology and access to critical care services.
We have a good working relationship with our GPs and one local GP sits on our
Medical Advisory Committee
Our nominated charity for last year was the Cornwall air ambulance service and we
raised over £462. We will continue to support this important Charity this year.
We advertise our services in the local press and local Radio.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle Bodmin NHS Treatment Centre develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to
improve clinical safety and standards by a systematic process of governance including
audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The priorities
are determined by the hospitals 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.
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Priorities for improvement
2.1.1
A review of clinical priorities 2013/14
Surgical safety checklist – compliance to the checklist has remained an ongoing quality
initiative at Bodmin NHS Treatment Centre. All the medical and clinical staff have had
training and have been actively involved in achieving compliance to the checklist.
Specific checklists for cataract surgery, LA Surgery and Endoscopy are used to further
reduce the risk of wrong site surgery/procedure.
Venous-thromboembolism assessment - (VTE) is a significant patient safety issue and
Bodmin Treatment Centre has an excellent VTE risk assessment compliance record. The
results for the past 12 months are all above the target 90%.
Never events - preventative measures have been implemented and there have not been
any “Never event” incidents in this reporting year at Bodmin Treatment Centre
Meeting endoscopy standards – Bodmin NHS Treatment Centre achieved JAG
accreditation in 2009 and the appointed endoscopy lead and staff involved in endoscopy
continuously submit data in line with the GRS initiative for endoscopy
Real Time incident reporting – In 2012 Ramsay invested in a new Risk Management
reporting system called RISKMAN and this has been successfully installed at Bodmin NHS
Treatment Centre enabling staff to achieve real time report
Clinical training – Bodmin NHS Treatment Centre continues to ensure that the patients
are cared for by safe and competent staff. Training is competency based and all staff
have been provided with training to assist them achieve the required competency level.
ILS and ALS training is mandatory for clinical staff working in acute areas. We also
provide AIM (Acute Illness Management) training for all clinical staff. Infection control
training, which includes hand hygiene, is mandatory for all staff.
Blood transfusion - there is a robust competency framework for the staff involved in the
administration of blood transfusion. All staff at Bodmin NHS Treatment Centre who are
involved in any aspect of blood transfusion or handle blood products have achieved the
required competency in blood transfusion administration.
Safeguarding- in house training in dealing with vulnerable adults, deprivation of liberty
and child protection is provided. Members of the senior management team have also
Quality Accounts 2013/14
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had external safeguarding training provided by the local council to improve staff
awareness of safeguarding policy. Equality, diversity and human rights are an essential
part of our training programme. Ramsay HealthCare’s integrated governance framework,
Group policies and practice comply with current legislation.
Staffing – last year we implemented an electronic staffing system which is now widely
used in the hospital to ensure adequate numbers of skilled staff are available to care for
the patients. Staff rotas are prepared in advance and reviewed daily in line with activity
numbers and dependency scores.
2.1.2
Clinical Priorities for 2014/15
Patient safety
Surgical safety checklist – compliance to the checklist will remain an ongoing quality
initiative at Bodmin NHS Treatment Centre. Compliance to the surgical safety checklist
will continue to be audited and the results reviewed at theatre departmental meetings,
Clinical Governance and Risk Management meetings.
Venous-thromboembolism assessment – will remain an ongoing quality initiative and we
will continue to audit our compliance to risk assessment and appropriate prophylaxis.
Audit results will be reviewed at the Clinical Governance Committee.
Never events - preventing the occurrence of any serious, largely preventable patient
safety incidents that should not occur will remain a clinical priority for 2014/15.
Training – Bodmin NHS Treatment Centre will continue to ensure that patients are cared
for by safe and competent staff. In addition to our robust competency based training
programme we have also introduced PREVENT Awareness Training. This training
commenced in 2014, for all staff and has been added to our in house training program.
Prevent self assessment tool completed.
Information Security – in 2011 Bodmin NHS Treatment Centre achieved the information
security accreditation IS0270001. This year the BSI Auditors will be carrying out a recertification audit of Bodmin Treatment Centre in November. An internal audit by
Ramsay’s Corporate Information Governance team will be carrying out an internal audit
in September 2014 in preparation for the external re certification. The process of raising
awareness of the importance of data protection and information security has been very
successful and fully embraced by the staff at Bodmin NHS Treatment Centre
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Pathways – for 2014-15 we are reviewing our clinical pathways with the aim of reducing
patient visits to our unit. At present we already run a very popular “See and Treat”
cataract service and a “one stop “diagnostic urology clinic. Recently we have introduced
a see and treat knee arthroscopy service listing patients for surgery directly from the
MSK clinic. Going forward we aim on expanding these services and hopefully introducing
more.
Clinical Effectiveness
Ambulatory Day Care – better outcomes and improving patient experience. Ambulatory
day care is the admission of selected patients to hospital for a planned procedure,
returning home the same day. Over recent years, partly due to medical advances, the
number of day surgery patients has increased compared to those patients requiring
inpatient care. Bodmin NHS Treatment Centre is a purpose built day case facility which
has adopted efficient patient pathways with an average length of stay of 2.28 hours. Best
practice has shown that by caring for short stay patients in a day care facility, as opposed
to a traditional ward, patient care will improve as the waiting time and recovery period
are reduced.
Pre assessment - Bodmin NHS Treatment Centre is a day case facility and we screen all
patients prior to admission to identify the level of care they will require during their stay.
Some are deemed too complex for treatment at this site and are referred to a more
appropriate facility to meet their needs. Others are admitted with their level of care
already defined and the necessary skilled staff, equipment and facilities available for
them. Pre assessing patients at the start of their pathway is performed by highly skilled
staff and conducted by either telephone assessment or a face to face examination.
Correctly assessing our patient’s needs is an ongoing quality initiative for Bodmin NHS
Treatment Centre.
National benchmarking VTE risk assessment compliance – benchmarking through the national stats website.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/D
H122283
PROMS results – benchmarking through national PROMS website
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http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID1295
Patient experience
Patient reported outcome studies (PROMS) – we participate in the national PROMS data
collection for Hernia surgery. The results, when available, will be reviewed by the
Medical Advisory Committee and Clinical Governance Committee.
Friends and Family Survey – Bodmin also participates in this survey on a local rather than
national level. Our latest results show that 100% of our patients would definitely
recommend Bodmin Treatment Centre to their friends and family.
Patient satisfaction survey – Bodmin NHS Treatment Centre’s patient survey is
consistently over 96%. The most recent results achieving 96.9% with 100% of patients
recommending Bodmin Treatment Centre. If we fall short of any patients’ expectations
and receive any poor results an action plan is completed and discussed at our Customer
Focus Group to enable an improvement in the patient experience.
PLACE Assessments – Bodmin Treatment Centre has received excellent results from this
patient led assessment of the hospital.
http://www.efm.ic.nhs.uk
2.2 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
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During 2013/14 Bodmin NHS Treatment centre provided and/or subcontracted 9 NHS
services.
Bodmin NHS treatment Centre has reviewed all the data available to them on the
quality of care in 9 of these NHS services.
Ramsay uses a balanced scorecard approach to give an overview of audit results across
the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed
each year. The scorecard is reviewed each quarter by the hospitals senior managers
together with Regional and Corporate Senior Managers and Directors. 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 2013/14, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources
Staff Cost 38% of Revenue
HCA Hours as 36% of Total Nursing
Staff Turnover 7.3%
Sickness 4.39%
Lost Time 18.2%
Appraisal 100%
Mandatory Training 79%
Staff Satisfaction Score 76.8% up from 67% in 2012
Number of Significant Staff Injuries - 0
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Patient
Formal Complaints per 1000 HPD's 0.1%
Patient Satisfaction Score – 96.8%
Significant Clinical Events per 1000 Admissions - 0
Readmission per 1000 Admissions -
Quality
Workplace Health & Safety Score – 95%
Infection Control Audit Score above 95%
2.2.2 Participation in clinical audit.
Bodmin Treatment Centre does not participate in any of the National Clinical audits as
they are not applicable to the services provided
Local Audits
The reports of all local audits which include; Anaesthetics, Medical records, Consent,
Discharge, Care Pathways & Variance tracking, Medicines Management, Controlled
drugs, Environmental, Termination of Pregnancy, Colposcopy, JAG & GRS and 9 infection
prevention & control audits from 1st April 2013 to 31st March 2014 were reviewed by
the Clinical Governance Committee and hospital’s MAC.
All audit results showed an excellent degree of compliance and our main priority for
2014/15 will be ensuring standards of documentation are met with regard to discharge
of patients. This is in line with the requirements of the National Standard Contract for
NHS services.
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The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 to participate in research approved by
a research ethics committee. Recently, however, we have met with the Peninsula
Comprehensive Clinical Research Network in order to provide access for patients,
accessing NHS care through non NHS providers such as Bodmin Treatment Centre, to
participate in research if they wish to.
2.2.4 Goals agreed with our Commissioners using the
CQUIN (Commissioning for Quality and Innovation)
Framework
A proportion of Bodmin NHS Treatment Centre’s income in from 1 April 2013 to 31st
March 2014 was conditional on achieving quality improvement and innovation goals
agreed Bodmin NHS Treatment Centre and any person or body they entered into a
contract, agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework
2.2.5 Statements from the Care Quality Commission
(CQC)
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Bodmin NHS Treatment Centre is required to register with the Care Quality Commission
and its current registration status on 31st March 2014 is registered without
conditions/registered with conditions.
The Care Quality Commission has not taken enforcement action against Bodmin NHS
Treatment Centre during 2013/2014.
Bodmin NHS Treatment Centre has not participated in any special reviews or
investigations by the CQC during the reporting period.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your Data Quality
We regularly use statistical data to monitor clinical services- we are constantly striving to
improve this data by regular quality control initiatives.
Data contained in medical records are audited on a monthly basis and actions taken to
improve quality as appropriate.
The hospital has a data quality super user who manages the SUS pathway processes and
continually reviews administration functions to ensure data quality.
NHS Number and General Medical Practice Code Validity
Bodmin NHS Treatment Centre submitted records during 2013/14 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are
included in the latest published data. The percentage of records in the published data
which included:
The patient’s valid NHS number:
99.97% for admitted patient care
99.96 for outpatient care
0% for accident and emergency care (not undertaken at our hospital)
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The General Medical Practice Code:
100% for admitted patient care;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital)
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score for
2013/14 was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Bodmin NHS Treatment centre was not subject to the Payment by Results clinical coding
audit during 2013/14 by the Audit Commission.
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2.2.7 Stakeholders views on 2013/14 Quality Account
Statement from Kernow Clinical Commissioning Group for Bodmin Treatment Centre
Quality Account 3013/14
Kernow Clinical commissioning Group is pleased to have the opportunity to comment on
the Quality Account 2013/14 for Bodmin treatment Centre (BTC) and welcomes the
approach the Centre has shown in developing and setting out its plans for quality
improvement. There are routine processes in place with BTC to agree, monitor and
review the quality of services throughout the year covering the key quality domains of
safety, effectiveness and experience of care.
We have reviewed and confirm the information presented in the Quality Account
appears to be accurate and fairly interpreted from the data collected.
The Quality Account presents an overview of a range of quality improvement work being
undertaken. We note the continued high patient satisfaction and patient reported
outcome measures, although would like to see further work on ensuring the response
rate from the Friends and Family survey increases in line with national levels.
We are pleased the recommendations from the PLACE assessment have been auctioned
which should ensure the responses in the privacy and dignity domain will match the
excellent results in other areas.
We are pleased to see the priorities chosen for 2013/14 are evidence based and have a
continued focus on patient safety, both through the surgical safety checklist, the
prevention of never events and the Venous-thromboembilism assessment.
Kernow Clinical Commissioning Group looks forward to working with the Treatment
Centre throughout the year to achieve more efficient pathways delivering high quality
services to patients.
Quality Accounts 2013/14
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Jacqueline Doane - Matron
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay Quality
Accounts. Through each year, month on month, we analyse our performance on many
levels, we reflect on the valuable feedback we receive from our patients about the
outcomes of their treatment and also reflect on professional opinion received from our
doctors, our clinical staff, regulators and commissioners. We listen where concerns or
suggestions have been raised and, in this account, we have set out our track record as
well as our plan for more improvements in the coming year. This is a discipline we
vigorously support, always driving this cycle of continuous improvement in our hospitals
and addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient privacy
and dignity, hospital safety and good outcomes of treatment. We believe in being open
and honest where outcomes and experience fail to meet patient expectation so we take
action, learn, improve and implement the change and deliver great care and optimum
experience for our patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)
Ramsay Clinical Governance Framework 2014
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.
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It is important that Clinical Governance is integrated into other governance systems in
the organisation and should not be seen as a “stand-alone” activity. All management
systems, clinical, financial, estates etc, are inter-dependent with actions in one area
impacting on others.
Several models have been devised to include all the elements of Clinical Governance to
provide a framework for ensuring that it is embedded, implemented and can be
monitored in an organisation. In developing this framework for Ramsay Health Care UK
we have gone back to the original Scally and Donaldson paper (1998) as we believe that
it is a model that allows coverage and inclusion of all the necessary strategies, policies,
systems and processes for effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
Quality Accounts 2013/14
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National 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 NHS Commissioning Board Special Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and selecting
those that are applicable to our business and thereafter monitoring their
implementation.
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3.1 The Core Quality Account indicators
Mortality
Mortality:
Expected
deaths:
Period
Best
Worst
Average
Period
Bodmin
2012/13
RKE
0.65
RXL
1.17
Eng
1
2012/13
NVC24
0
2013/14
RKE
0.63
RBT
1.15
Eng
1
2013/14
NVC24
0.01
Period
Best
Worst
Average
Period
Bodmin
Apr12 - Mar13
RBA
0.1
RWH
44.0
Eng
20.4
2012/13
NVC24
0.0
Jul12 - Jun13
RBA
0.0
RWH
44.1
Eng
20.2
2013/14
NVC24
0.0
The data made available to the National Health
Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard
to—
(a) the value and banding of the summary hospitallevel mortality indicator (“SHMI”) for the trust for
the reporting period; and
(b) The percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level for the trust for the reporting
period.
*The palliative care indicator is a contextual
indicator.
1: Preventing People from dying
prematurely
2: Enhancing quality of life for people
with long-term conditions
Bodmin NHS Treatment Centre does not have any palliative care facilities
PROMS
PROMS:
Period
Hernia
Apr12 - Mar13
NT415
0.157
NVC27
0.015
Eng
0.085
Apr12 - Mar13
NVC24
0.083
Apr13 - Sep13
RTG
0.138
RNA
0.019
Eng
0.086
Apr13 - Sep13
NVC24
*
PROMS:
Veins
PROMS:
Hips
PROMS:
Knees
Best
Period
Worst
Best
Average
Worst
Average
Period
Period
Bodmin
Bodmin
Apr12 - Mar13
RV8
5.14
NT350
-15.92
Eng
-8.374
Apr12 - Mar13
NVC24
Apr13 - Sep13
RTD
-9.74
RLN
-10.52
Eng
-9.46
Apr13 - Sep13
NVC24
Period
Best
Worst
Average
Period
Bodmin
Apr12 - Mar13
NT209
24.68
RKE
17.21
Eng
21.32
Apr12 - Mar13
NVC24
Apr13 - Sep13
NT318
25.44
RHQ
18.34
Eng
21.61
Apr13 - Sep13
NVC24
Best
Period
Worst
Average
Period
Bodmin
Apr12 - Mar13
NT219
20.37
RAP
12.46
Eng
16.01
Apr12 - Mar13
NVC24
Apr13 - Sep13
RDE
20.09
RM1
14.32
Eng
16.74
Apr13 - Sep13
NVC24
The data made available to the National Health 3: Helping people to recover from
Service trust or NHS foundation trust by the Health episodes of ill health or following injury
and Social Care Information Centre with regard to
the trust’s patient reported outcome measures
scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery,
during the reporting period.
Bodmin NHS Treatment Centre considers that this data is as described for the
following reasons: Bodmin only undertakes the Hernia proms.
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Readmissions
Readmissions:
Period
Best
Worst
Average
Period
Bodmin
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2012/13
NVC24
0
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
2013/14
NVC24
0
The data made available to the National Health 3: Helping people to recover from
Service trust or NHS foundation trust by the Health episodes of ill health or following injury
and Social Care Information Centre with regard to
the percentage of patients aged—
(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital which forms part of the
trust within 28 days of being discharged from a
hospital which forms part of the trust during the
reporting period.
Bodmin NHS Treatment Centre considers that this data is as described for the
following reasons. There have been no readmissions in the last year.
Personal needs
Responsiveness
Period
Best
Worst
Average
Period
Bodmin
to personal
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC24
0.0
needs
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC24
0.0
The data made available to the National Health 4: Ensuring that people have a positive
Service trust or NHS foundation trust by the Health experience of care
and Social Care Information Centre with regard to
the trust’s responsiveness to the personal needs of
its patients during the reporting period.
Bodmin NHS Treatment Centre data is taken from the Ramsay patient Survey and not
the CQC in patient survey as we do not have in patients.
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VTE
VTE
Assessment:
Period
Best
Worst
Average
Period
Bodmin
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q3
NVC24
95.9%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
13/14 Q4
NVC24
95.8%
The data made available to the National Health 5: Treating and caring for people in a
Service trust or NHS foundation trust by the Health safe environment and protecting them
and Social Care Information Centre with regard to from avoidable harm
the percentage of patients who were admitted to
hospital and who were risk assessed for venous
thromboembolism during the reporting period.
Bodmin NHS Treatment centre considers that this data is as described for the following
reasons: Not all patients in the day unit require VTE assessments, but we aim to
improve our scores to above 96% in the next year
C.Diff rate
C. Diff rate:
Period
Best
Worst
Average
Period
Bodmin
per 100,000
2012/13
Several
0
RNA
58.2
Eng
22.2
2012/13
NVC24
0.0
bed days
2013/14
Several
0
RVW
30.8
Eng
17.3
2013/14
NVC24
0.0
The data made available to the National Health 5: Treating and caring for people in a
Service trust or NHS foundation trust by the Health safe environment and protecting them
and Social Care Information Centre with regard to from avoidable harm
the rate per 100,000 bed days of cases of C difficile
infection reported within the trust amongst
patients aged 2 or over during the reporting
period.
There have been no episodes of C.Diff at Bodmin NHS Treatment Centre.
Our aim is to protect all out patients and treat them in a safe environment.
Quality Accounts 2013/14
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Incidents
Incident Rate:
Period
Patient Safety
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
NVC24
0.38
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
2013/14
NVC24
0.57
SUIs:
(Severity 1
only)
Best
Period
Worst
Best
Average
Worst
Average
Jul - Sep 12
NA
NA
NA
Oct11 - Sep12
NA
NA
Eng
11,563
Period
Period
Bodmin
Bodmin
2012/13
NVC24
0.0%
2013/14
NVC24
10.0%
The data made available to the National Health 5: Treating and caring for people in a
Service trust or NHS foundation trust by the Health safe environment and protecting them
and Social Care Information Centre with regard to from avoidable harm
the number and, where available, rate of patient
safety incidents reported within the trust during
the reporting period, and the number and
percentage of such patient safety incidents that
resulted in severe harm or death
Bodmin NHS Treatment Centre considers that this data is as described for the
following reasons; The NRLS does not appear to offer any break down of aggregate
figures.
Figures are percentage of patient safety events that are severe or death.
Bodmin NHS Treatment centre has had no Serious untoward Events in the past year.
Friends and Family
F&F Test:
Period
Best
Worst
Average
Period
Bodmin
Jan-14
Several
100
RPA02
27
Eng
73
2012/13
NVC24
0
Feb-14
Several
100
RPA02
18
Eng
73
2013/14
NVC24
0
Friends and Family Test - Question Number 12d – 4: Ensuring that people have a
Staff – The data made available by National Health positive experience of care
Service Trust or NHS Foundation Trust by the
Health and Social Care Information Centre ‘If a
friend or relative needed treatment I would be
happy with the standard of care provided by this
organisation' for each acute & acute specialist
Quality Accounts 2013/14
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trust who took part in the staff survey.
Bodmin NHS Treatment Centre did not take part in the national staff survey.
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every year
and in all performance respects, and certainly in regards to our track record for patient
safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more routinely
from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of key
indicators as illustrated in the graphs below.
3.2.1 Infection prevention and control
Bodmin NHS Treatment Centre has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents
year on year.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic
joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a corporate level Infection Prevention and Control (IPC)
Committee and group policy is revised and re-deployed every two years. Our IPC
programmes are designed to bring about improvements in performance and in practice
year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
As seen below at Bodmin NHS Treatment Centre the rates of recorded infections have
improved since 2011/2012.
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Infection Rates
Infection Rates
(percentage of Admissiosns)
0.06
0.05
0.04
0.03
0.02
0.01
0
2011/12
2012/13
2013/14
Bodmin NHS Treatment Centre
3.2.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient-Led Assessments of
the Care Environment (PLACE)
PLACE assessments occur annually at Bodmin NHS Treatment Centre, providing us with
a patient’s eye view of the buildings, facilities and food we offer, giving us a clear
picture of how the people who use our hospital see it and how it can be improved.
The main purpose of a PLACE assessment is to get the patient view.
There were some improvements to be made in Privacy and dignity surrounding the
outpatient area, where patients could overhear conversations with other patients. This
has now been addressed and all actions completed.
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3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high awareness
of safety has been a foundation for our overall risk management programme and this
awareness then naturally extends to safeguarding patient safety. Our record in
workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the
results of safety training and local safety initiatives.
Effective and ongoing communication of 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.
Health and Safety audit was 95%
Health and Safety training is provided to all staff annually.
Manual handling training provided to all staff annually.
3.3 Clinical effectiveness
Bodmin NHS Treatment Centre 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.
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3.3.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes.
As seen in the graph below we had one return to theatre in 2013. Our aim is to have no
returns as we did in 2011 and 2012.
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.06
0.05
0.04
0.03
0.02
0.01
0
2011/12
2012/13
2013/14
Bodmin NHS Treatment Centre
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care are
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
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All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the relevant
staff using direct feedback. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular agenda
items on Local Governance 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:










Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers
whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of the
hospital so we receive a true reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked are
used to influence the way the hospital seeks to improve its services. Any text comments
made by patients on their survey are sent as ‘hot alerts’ to the Hospital Manager within
48hrs of receiving them so that a response can be made to the patient as soon as
possible.
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As shown in the graph below, although there was a slight drop in satisfaction over the
last year 97% is still very high. Our aim is to improve our satisfaction scores over the next
year.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
99.3
97.0
2012/13
2013/14
20
0
Bodmin NHS Treatment Centre
Quality Accounts 2013/14
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Services covered by this quality account
Appendix 1
Services covered by this quality account
Bodmin NHS Treatment Centre
The Treatment Centre opened in January 2006 and is one of ten centres
across the UK where Ramsay is working in partnership with the NHS.
Ramsay’s reputation is built on high standards of in patient care in the
private sector. Our aim is to combine this experience of providing quality
healthcare with that of our NHS partners.
Bodmin Treatment Centre, Boundary Road, Bodmin, Cornwall PL312QT
Tel: 01208 262520
Registered Manager: Kathie Rimmer
Kathie.rimmer@ramsayhealth.co.uk
Services Provided
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Outpatient
services
Cosmetic,
Dermatological,
Gastroenterology,
Gynaecology,
General
surgery,
Maxillofacial
/
oral,
Ophthalmic,
Orthopaedic. ENT
Ambulatory and Day Surgery, Cosmetic,
Dermatological,
Gastroenterology,
Gynaecology
General
surgery,
Maxillofacial
/
oral,
Ophthalmic,
Orthopaedic. ENT ,Urology
Peoples Needs Met for:
All adults 18 yrs and over
All young person’s age 16-18yrs consultation for termination of
pregnancy procedures only
.
All young person’s age 16-18yrs for termination of pregnancy
procedures only
All adults 18yrs and over excluding:












Patients with blood disorders (haemophilia, sickle cell,
thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA screen are
deferred until negative
Patients who are likely to need ventilatory support post
operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to ITU
post-surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild exertion
e.g. from kitchen to bathroom or dyspnoea at rest)
Poorly controlled asthma (needing oral steroids or has had
frequent hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal activity e.g.
1 flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we will only
exclude patients if we are unable to provide an appropriate and safe
clinical environment.
All patients must meet social/clinical criteria for day surgery.
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Appendix 2 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
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Bodmin NHS Treatment Centre
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:
Bodmin Treatment Centre on 01208 262520
www.bodmintreatmentcentre.co.uk
Quality Accounts 2013/14
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