Boston West Hospital
Quality Account
2013/14
Quality Accounts 2013/14
Page 1 of 52
Contents
Introduction Page
Welcome to Ramsay Health Care UK
3
Introduction to our Quality Account
4
PART 1 – STATEMENT ON QUALITY
5
1.1
Statement from the General Manager
5
1.2
Hospital accountability statement
7
PART 2
15
2.1
15
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
15
2.1.2 Clinical Priorities for 2014/15 (looking forward)
16
2.2
20
Mandatory statements regarding quality of NHS services
2.2.1 Review of Services
20
2.2.2 Participation in Clinical Audit
23
2.2.3 Participation in Research
25
2.2.4 Goals agreed with Commissioners
25
2.2.5 Statement from the Care Quality Commission
27
2.2.6 Statement on Data Quality
27
2.2.7 Stakeholders views on 2013/14 Quality Accounts
29
PART 3 – REVIEW OF QUALITY PERFORMANCE
34
3.1
The Core Quality Account indicators
36
3.2
Patient Safety
40
3.3
Clinical Effectiveness
44
3.3
Patient Experience
45
3.4
Case Study
47
Appendix 1 – Services Covered by this Quality Account
49
Appendix 2 – Clinical Audits
50
Appendix 3 – Glossary
51
Quality Accounts 2013/14
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Welcome to Ramsay Health Care UK
Boston West 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 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)
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Introduction to our Quality Account
This Quality Account is Boston West 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 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
Carl Cottam General Manager
Boston West Hospital
As the General Manager of Boston West Hospital I am passionate about ensuring
that we deliver consistently high standards of care to all of our patients.
Our Vision is that:
“As a committed team of professional individuals we aim to consistently deliver
quality holistic care for all of our patients across a full range of care services. We
believe we are able to achieve this by continually updating our key skills and
knowledge enabling us to deliver evidence based clinical practice throughout the
Hospital. Boston West Hospital is a recognised Centre of Excellence for the
delivery of day case services”.
Our Quality Account details the actions that we have taken over the past year to
ensure that our high standards in delivering patient care remain our focus for
everything we do. Through our vigorous audit regime, and by listening to all our
stakeholders, including patient feedback, we have been able to identify areas of
good practice and where we can improve the care our patients receive. This has
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enabled us to refine some of our processes which have resulted in making further
improvements.
To ensure that we deliver clinical excellence depends on the whole team. We
have an excellent training and education plan which involves all members of our
administrative and clinical teams.
Every individual member of staff is crucial to the success of our hospital and we
value the contribution that they make in delivering great customer care.
Our Quality Account has been produced to provide information about how we
monitor and evaluate the quality of the services that we deliver.
We hope to be able to share with the reader our progressive achievements that
have taken place over the past 2-3 years. Boston West Hospital has a very strong
track record as a safe and responsible provider of health care services and we
are proud to share our results.
Our Quality Accounts have been developed with the involvement of our staff who
have been instrumental in developing a systems approach to risk management,
which focuses on making every effort to reduce the likelihood and consequence
of an adverse event or outcome associated with treatment of a patient.
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the Hospital.
These committees have reviewed and agree with the content and action details
within these Quality Accounts.
As the General Manager I am aware of all aspects of clinical quality and NHS
services provided at Boston West Hospital and can confirm the accuracy of this
document.
If you would like to comment or provide me with feedback then please do contact
me on carl.cottam@ramsayhealth.co.uk or telephone: 01733 842329.
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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.
Carl Cottam
General Manager
Boston West Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Medical Advisory Committee Chair:
Mr. V. Csok
Clinical Governance Committee Chair:
Mr. M. Necas
Regional Director, Midlands Region,
Ramsay Health Care:
Mr. James Beech
The Patient & Public Involvement Forum Committee Members
South Lincolnshire Clinical Commissioning Group
Lincolnshire Health Watch
Lincolnshire Health Overview and Scrutiny Committee
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Welcome to Boston West Hospital
Boston West Hospital is a purpose built facility which provides services for
assessment, diagnosis and treatment of common medical conditions, and has a
suite of outpatient and treatment rooms which has recently been refurbished to
create an additional spacious consultation room. A well-equipped modern theatre
undertakes a range of surgical procedures and endoscopic (diagnostic)
investigations. Support services include a three stage Sterile Services Unit,
which meets the stringent standards set by the Department of Health.
The Hospital provides NHS and private day case facilities for the following
specialties:
Orthopaedic
Ophthalmology
General Surgery
Pain Management
Gynaecology
Gastroenterology
Urology
Physiotherapy
Cosmetic Surgery
Our full list of services can be found in Appendix 1.
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We provide safe, convenient, effective and high quality treatment for adult
patients (excluding children below the age of 18 years), whether privately insured,
self-pay, or from the NHS. A high percentage of our patients have come from the
NHS sector, patients choosing to use our facility through ‘Choose and Book’. Our
services help to ease the pressure on The Pilgrim NHS Hospital and Lincoln
County Hospital and other local NHS facilities. We have worked closely with the
Hospital Management Team and our NHS Clinical Commissioners, Lincolnshire
South CCG, to ensure improved access for patients requiring day case surgery.
We have close links with GP surgeries, providing information, training and liaison
in order to monitor their needs and the requirement of the local population. We
look forward to building strong relationships and working closely with all of the
Lincolnshire Clinical Commissioning Groups (CCGs)
During the past year 8628 patients have attended outpatient clinics at our
hospital. We have treated a total of 2,595 day case surgical patients which is an
increase of 382 on the previous year. Of those patients 2,487 (95.84%) were
NHS patients, and 108 (4.16%) private insured and self pay patients.
Boston West Hospital has a fully accredited Sterile Services Unit, compliant to the
latest decontamination regulations and legislation.
We currently employ the following staff at Boston West Hospital:
1 General Manager (covering 2 hospitals)
1 Matron / Clinical Lead
1 Administration / Bookings Manager
4 Receptionist / Administrators and 2 Medical Secretaries all of whom work
part time
1 Liaison Officer
2 employed Consultants - a Consultant General Surgeon and a Consultant
Anaesthetist.
We also work with 26 consultants who have practicing privilege credentials
with Ramsay, the majority of which also work at the local NHS trust.
6 Registered Nurses, 2 Operating Department Practitioners(ODP), and 3
Health Care Assistants
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6 Sterile Services Technicians
3 Housekeeping Staff
1 Supplies / Maintenance Coordinator
We also have a shared Accountant, Engineer, HR Coordinator, and
Clinical Coder with another local Ramsay hospital
We have a number of regular Bank Nursing, ODP, Sterile Services
Technicians and Housekeeping Staff.
A Consultant Anaesthetist is on site when the unit is in operation with patient
procedures, along with a minimum of 1 Advanced Life Support (ALS) Trained
Nurse
We work in close partnership with commissioners to deliver day care surgery to
the residents of Lincolnshire, and also with the Pilgrim Hospital, United
Lincolnshire Hospital Trust (ULHT) utilising Radiology, Pathology and
Occupational Health Services. We have agreements in place for the transfer of
critically and non critically ill patients and for direct fast track transfer of patient
care into the cancer networks.
Patient engagement and involvement has been a high priority for the past year as
we continue to keep patients at the heart of everything we do.
Our Patient Group continues to develop and plays the valuable role of ‘critical
friend’ to the Hospital. In addition to conducting our recent PLACE assessment
patients have been involved with our Disability Discrimination Act audit, and have
undertaken a review of all patient communication including patient discharge
information and the Hospital website to ensure that it is patient friendly.
Patient feedback has become a real driver for improvement and the comments
we receive both via internal evaluation ‘We Value Your Opinion’ and external
evaluation ‘Family and Friends’ and ‘NHS Choices’ are reviewed regularly by our
Department Heads and the Hospitals Senior Management Team.
The introduction of a new web based patient survey means that we are now able
to gather even more valuable patient opinion and utilise this as we constantly
strive to improve our services. Currently 97% of patients would recommend
Boston West Hospital to family and friends.
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“Absolutely fabulous service, knowledgeable friendly staff, wonderful
care. I will recommend you to everyone I know who needs any treatment
and am looking forward to having my other eye done!”
V Timms - (Cataract patient 2013)
In addition to patient involvement our Liaison Officer works closely with GP
Practices, Opticians and communities across the county to ensure that both
referrers and patients are aware of our services and that these services meet the
needs of local people.
During the past year we have developed a programme of free clinical education
to support health professionals in their continued education and training. This
has been well received by GPs, Optometrists and trainees and has also helped
us strengthen relationships and improve communication between our Consultants
and local clinicians. These educational sessions have been delivered by our
Consultants, Clinical and Theatre leads at GP Practices throughout Lincolnshire
and at the hospital itself. GPs have also attended outpatient clinics as observers
to further increase their knowledge and understanding of certain specialities such
as pain management.
Boston West Hospital is approved by the General Optical Council as a provider of
continued education and training (CET) enabling us to deliver accredited training
to Optometrists, dispensing Opticians and support staff.
“The Ramsay Trainer explained the whole session with a full and thorough
understanding of Choose and Book. Easy to understand and a very useful
morning” P Goodman - Westside Surgery
“Well presented and very informative, gave a clear idea as to how to deal with
shoulder pain” P Sharma GP Registrar
“Excellent and thorough presentation providing information for use in practice
and when dealing with patients” D Enderby – Enderbys Opticians
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We are always happy to showcase our hospital and this year have welcomed
visits from patient and community groups, GP Practice staff, members of the
Health Scrutiny Committee for Lincolnshire and Member of Parliament Mr Mark
Simmonds pictured below with members of the Boston West Hospital Team.
“I was delighted to visit Boston West Hospital and meet with staff. Due to
the introduction of Patient Choice, NHS patients can use this fantastic
facility and take advantage of the great healthcare which is offered here.”
Mark Simmonds MP (Boston and Skegness)
Boston West Hospital has participated in health road shows organised with
partners all working within provision of health and wellbeing services along the
local East coast where local people could come and find out more about the
services we. We supported the Boston United Football Club Community Day, an
event primarily promoting health and wellbeing through sport and activity but
another good opportunity to engage with local people and promote patient choice.
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We continue to work closely with partners and regularly invite health and
wellbeing providers to display information relating to community services in our
reception area and provide advice to patients, relatives and carers where
appropriate. St Barnabas Hospice and Lincolnshire County Council Health
Trainers are organisations which have found this to be useful and we feel it
provides a holistic approach to our patient’s long term wellbeing.
Hospital Staff have been
working together with
patients to raise funds
for charity. This year
Pancreatic Cancer Care
and Fenbank Greyhound
Sanctuary were the
chosen charities.
Ramsay Health Care has
donated resources and
staff have volunteered
time to arrange
fundraising activities and
raffles.
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Patients tell us how important good customer service is to their experience of
healthcare in our hospital. In response we have introduced a Customer Service
Excellence programme (CSE) to encourage excellence in our staff and recognise
members of the Boston West team who demonstrate excellent customer service.
Staff who demonstrate exceptional care, attention and support can be nominated
by patients, carers, visitors and colleagues and work their way to bronze, silver
and the ultimate gold CSE award. To date members of our clinical,
administration, housekeeping and sterile services departments have achieved
bronze and in some cases silver awards and are working hard to achieve the
gold.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Boston West Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives 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.
Priorities for improvement
2.1.1 A review of clinical priorities 2013/14 (looking back)
Dementia Screening – We worked in collaboration with Clinical Commissioning
Groups to adapt national CQUIN’s to enable the hospital to participate in a
national campaign. We were committed to a programme of identifying any
patients over the age of 75 that displayed signs and symptoms of dementia and
referred them to the appropriate care providers. This was undertaken by nurses
that were trained specifically to identify patients with early signs of dementia as
part of our pre-assessment service.
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Patient Safety: Delivery of Compassionate Care – Compassion in care
delivery was a priority that was measured consistently throughout the year. A
variety of different tools are used to measure effectiveness of care and these
include patient feedback, complaints, inspections and daily observation from
senior clinical staff. Lack of compassion was not a theme identified as part of
internal governance complaint reviews. The hospital has had an unannounced
CQC inspection, and a quality themed inspection, from Lincolnshire CCG as well
as internal inspections and audits all of which confirm the quality of care provided
was delivered to the required standards.
PLACE Assessment - The Frances report reiterated the importance of
monitoring healthcare practice through peer assessment. Our aspiration was not
only take part in the PLACE inspection but to formulate a patient and public forum
to inform and underpin the development of our service. The purpose of the
PLACE assessment was to review cleanliness, catering, environment and the
facilities provided. Our aim of developing a partnership through a forum allowed
patients and public to influence change and engage with us about our practice
and decision making.
Clinical Standards: EWS – One of the clinical standards for 2013/14 was linked
to CQUIN and looked at the early warning system (EWS). EWS provides a
structure within which nurses escalate concerns about deteriorating patients to
reduce clinical risk. Clinical audit has demonstrated improved compliance and
nurses have undergone comprehensive training to ensure they have the skills
and underpinning knowledge to deliver safe and effective care.
Clinical Effectiveness: Implementation of the Electronic Rostering System –
The hospital has successfully implemented an electronic rostering system that
has improved efficiencies and enabled monitoring of safe staffing levels.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient Experience
Patient experience continues to be a key focus that underpins every priority at
Boston West Hospital. Fostering an environment that enables us to learn from
patient feedback is critical to the growth and development of our service.
Patient Satisfaction – The hospital utilised patient satisfaction data gathered by
an external provider to identify areas for improvement. Having listened to our
patients we then worked in collaboration with our clinical commissioning groups to
identify CQUIN’s that would monitor and measure improvement in service through
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audit and patient satisfaction survey. The clinical priorities for 2014/15 will include
focus on pain management and information about pain management at point of
discharge.
Friends & Family – After the successful role out of day case friends and family
our next priority is the implementation of the friends and family survey in the outpatient department
Clinical Effectiveness
It is important for the patients who choose to be treated by our clinicians that the
procedures they undergo are effective and appropriate. We measure and record
how effective we are publishing data to inform and benchmark.
PROMS – Patient related outcomes measures are a clinical priority for 2014/15
and we are focusing on improving our response rates for groin hernias and
varicose veins. Patient outcome measures enable health care professionals to
measure the overall benefit of undertaking surgical procedures and the clinical
effectiveness of surgical procedures.
Patient Safety
It is important patients know that they are being cared for in a safe environment
by staff that are appropriately trained. There is also a contractual requirement to
demonstrate to the clinical commissioning groups that we achieve high standards
of clinical safety. This is done through numerous audits, reports and inspections.
VTE – One of our clinical priorities for 2014/15 continues to be minimizing the
number of VTE episodes by ensuring VTE risk assessments are completed on all
patients. We also continue to monitor that we give prescribe and administer
appropriate prophylaxis. All VTE episodes will have a full RCA investigation
report completed and lessons learnt disseminated. Our aim is to ensure over
98% patients have a completed risk assessment and appropriate prophylaxis
given, and 100% of VTE episodes have a full RCA completed within agreed time
scales with the CCG and monitored through audit.
EWS- CQUINs 2014/15 will include further training in relation and monitoring of
the effectiveness of training. This will be required following after a review of the
corporate early warning score resulted in changes being implemented to the
scoring system as a result of new national guidelines.
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Local / National CQUIN’s – 2014/15
Goal name
Indicator name
Indicator description
Friends and Family Test
Friends and Family Test - Early
Implementation
Early implementation
Friends and Family Test
Friends and Family Test - Increased or
maintained Response Rate
Increased response rate at both sites for Ramsay
Healthcare (Boston West Hospital Day case,
Fitzwilliam Hospital Inpatient and Day case)
Friends and Family Test
Friends and Family Test - Increased
Response Rate in inpatient (and
daycase where applicable) services
Increased response rates at both sites for Ramsay
Healthcare (Boston West Hospital Daycase,
Fitzwilliam Hospital Inpatient and Daycase)
NHS Safety Thermometer
NHS
Safety
Thermometer
Improvement Goal Specification. Falls
Maintenance of 13 14 falls performance (6 month
median to not deteriorate)
Dementia
Dementia - Find, Assess, Investigate
and Refer
The proportion of patients aged >75 admitted as an
elective admission undergoing a face to face preassessment, the proportion of those identified as
potentially having dementia who are appropriately
assessed, and the number referred on to specialist
services. Each patient admission can only be included
once in each indicator but not necessarily in the same
month, as the identification, assessment and referral
stages may take place in different months.
Dementia
Dementia - Clinical Leadership
Named lead clinician for dementia and appropriate
training for staff
Post Operative Pain Management
The indicator sets out to improve pain management
for all admitted patients, ensuring that patient’s pain is
scored using a nationally recognised pain scoring tool
and that appropriate action is taken according to pain
score each time a set of clinical observations is
recorded. (Exceptions will include 1st stage recovery
where the pain score is recorded as per Ramsay
policy and not at 5 minute intervals alongside clinical
observations)
Pain Management
CQUIN)
(Local
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Pain Management
CQUIN)
(Local
Post discharge pain management
The indicator sets to improve communication about
pain management for all admitted patients, ensuring
that all in patients have relevant and appropriate
literature and advice on discharge
Pain Management
CQUIN)
(Local
Post discharge pain management patient experience
The indicator sets to improve communication about
pain management for all admitted patients, ensuring
that all in patients have relevant and appropriate
literature and advice on discharge
EWS Compliance
Reduce clinical risk by implementing further change to
EWS chart incorporating national guidance into EWS
chart, train staff on use of new charts and monitor
compliance with escalation of deteriorating patient
Early Warning Score
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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
During 2013/14 Boston West Hospital provided 22 NHS services.
Boston West 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 1 April 2013 to 31st
March 14 represents 100 per cent of the total income generated from the
provision of NHS services by Boston West Hospital for 1 April 2013 to 31st March
14.
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
In 2013/14 our percentage of agency cost was 0% The expectation for 2014/15 is
that we will continue to recruit to permanent positions and retain permanent staff
as vacancies arise and to allow for the rise in patient through put to maintain the
avoidance in need of agency use. Lost time was particularly high this year at
14.6%. Due to long term sickness, maternity, new employee induction time and
training which all contributed to lost time. Staff costs as a percentage of net
revenue were 19.05%.
We continue to work with our ‘Well Being Service’ to support employees both in
the work place and as part of a structured return to work service.
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The total skill mix calculation for Boston West Hospital was worked out by
calculating all contracted hours for registered nurses and healthcare assistants.
65% of staff caring for patients is registered nurses.
35% of staff are health care assistants.
Boston West Hospital provides an ongoing training program for staff and monitors
compliance for various elements of mandatory training. This allows us to meet
contractual obligations as well as ensuring staff are competent and confident to
provide care.
Each year staff take part in a satisfaction survey, the results of which are
analyzed for common themes. The senior management team then devises a
strategy for progression.
Boston West Hospital provides an ongoing training program for staff and monitors
compliance for various elements of mandatory training. This allows us to meet
contractual obligations as well as ensuring staff are competent and confident to
provide care.
The senior management team then devises a strategy for progression. 2012/13
saw the implementation of an employee engagement group to drive forward
change led by employees.
There were no RIDDOR events recorded for Boston West Hospital during this
period.
Patient
The number of complaints per 1000 hospital patient days equates to 0.03%.
Themes and trends are monitored through the local clinical governance and
medical advisory committee. Corporate Ramsay has an overarching view of
governance and providing feedback and benchmarking information.
The annual audit program is inclusive of infection control and prevention. There is
a monthly program that addressing different areas of infection control and the
audit results ranged from 83% to 100% from 2013 to 2014. The corporate audit
program includes hand hygiene, isolation, peripheral venous cannula care
bundles, urinary catheter care bundles, surgical site surveillance and infection
and control environmental audits. Locally mattress audits and various other
departmental auditing are undertaken. The lower scoring clinical audits carried
out earlier in the year all showed significant improvement throughout the year with
action planning put in place to resolve any of the issues highlighted.
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Boston West Hospital utilises an external company to gather unbiased data with
regards to patient satisfaction. We analyze this information on a quarterly basis
and review the lowest scoring areas. An action plan is then drawn up to ensure
that we address the areas of concern that patients have highlighted through this
mechanism.
In quarter four 2013 88.9% of patients felt they were involved in decisions about
discharge and 88.9% of patients felt staff did everything they could to control
pain. To focus on and improve these scores we have chosen local CQUIN
initiatives to measure our improvements of management of pain control during
admission and in preparation for discharge.
Scores for time to admission, information given about condition and cleanliness of
room improved to 100%. Scores were maintained at 100% in 11 measures, with
overall satisfaction maintaining 100%, and 100% patients would recommend the
service to family and friends 100%.
We saw a drop in the monthly response rate, therefore a drive to promote our
external survey to encourage patients to leave feedback has been implemented.
However, we have a very good return of “we value your opinion” internal patient
satisfaction feedback and excellent response rate to the friends and family survey
for admitted patients.
We have a governance system in place to monitor all significant clinical events.
During the period of 2013/14 our overall percentage for significant events was
0%.
Readmissions are monitored for trends; all of the readmissions were successfully
discharged home. In percentage terms, the readmissions equated to 0% of our inpatients.
Quality
Our annual workplace health and safety score was 98%, which is an
improvement on the previous year. An action taken from the audit was to increase
our recycled waste, putting systems in place to facilitate this and providing staff
training to raise awareness and compliance.
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2.2.2 Participation in clinical audit
During 1st April 2013 to 31st March 2014, Boston West Hospital participated in
one national clinical audit.
The national clinical audits and national confidential enquiries that Boston West
Hospital participated in, and for which data collection was completed during 1 st
April 2013 to 31st March 2014, are listed below, alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
Cases
Submitted
Name of Audit / Clinical Outcome
Review Programme
102
Elective surgery (National PROMs Programme)
Not
enough
patients
National Audit of Seizures in Hospitals (NASH)
Not
enough
patients
Severe sepsis & septic shock*
N/A
Bowel cancer (NBOCAP)
N/A
Head and neck oncology (DAHNO)
N/A
Lung cancer (NLCA)
N/A
Oesophago-gastric cancer (NAOGC)
Acute coronary syndrome or Acute myocardial infarction (MINAP)
Cardiac Rhythm Management (CRM)
Congenital heart disease (Paediatric cardiac surgery) (CHD)
Coronary angioplasty
National Adult Cardiac Surgery Audit
National Cardiac Arrest Audit (NCAA)
Not
enough
patients
N/A
N/A
N/A
Not
enough
patients
Not
enough
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patients
N/A
National Heart Failure Audit
N/A
National Vascular Registry*
N/A
Pulmonary hypertension (Pulmonary Hypertension Audit)
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)*
N/A
Diabetes (Paediatric) (NPDA)
N/A
Inflammatory bowel disease (IBD)*
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme*
N/A
Rheumatoid and early inflammatory arthritis*
N/A
Falls and Fragility Fractures Audit Programme (FFFAP)
N/A
Sentinel Stroke National Audit Programme (SSNAP)*
N/A
Child health clinical outcome review programme (CHR-UK)*
N/A
Epilepsy 12 audit (Childhood Epilepsy)
Moderate or severe asthma in children (care provided in emergency
departments)*
Paediatric fever*
Paediatric intensive care (PICANet)
N/A
N/A
Paediatric bronchiectasis*
Paediatric asthma
N/A
N/A
N/A
N/A
N/A
The most up to date PROM’s data available from HSCIC is for the period March
2013 to December 2013. In that period we had 72 PROM’s returns, with
compliance being 81% for hernias and 67.7% for veins.
The reports one national clinical audit from 1st April 2013 to 31st March 2014, are
being reviewed by the Clinical Governance Committee and Boston West Hospital
intends to take the following actions to improve the quality of healthcare provided;
Improve processes around PROMs compliance and analyzing patient
outcomes
Quality Accounts 2013/14
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Local Audits
The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee to see what actions were
required to improve the quality of healthcare provided. The clinical audit schedule
can be found in Appendix 2.
Exceptions from audit findings are presented at clinical governance and the
medically advisory committee. An example of some of the exceptions reported
include a lack of evidence of the specific information leaflet given to patients
about their procedure to ensure patients can give an informed written consent.
Although evidence of written information is given, the detail of the leaflet was not
evident. Sessions were held with the nursing staff to raise awareness of this
requirement and folders of specialty specific leaflets made more readily available
to consultants in the consultation rooms. Variance to pathway in nursing
documentation not being completed 100% of the time in the perioperative phase,
and in completing the signature list. This audit was repeated and compliance
improved.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 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
A proportion of Boston West Hospital’s income in from 1st April 2013 to 31st March
2014 was conditional on achieving quality improvement and innovation goals
agreed by Boston West Hospital 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.
Further details of the agreed goals for 2013/14 and for the following 12
month period are available below.
Quality Accounts 2013/14
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Local / National CQUIN’s for Lincolnshire – 2013/14
Goal name
Friends and family
Indicator name
FFT – increased response rate
Indicator description
increased response rate
Friends and family
FFT -improved performance on staff friends
and family test
Improved performance on staff friends and family test
Dementia
Dementia -find, assess, investigate and
refer
The proportion of patients aged 75 and over to whom case
finding is applied following elective admission undergoing a
face to face pre-assessment , the proportion of those
identified as potentially having dementia who are
appropriately assessed, and the number referred on to
specialist services
VTE
VTE risk assessment
% of all adult in-patients who have had a VTE risk assessment
on admission to hospital using the clinical criteria of the
national tool
VTE
VTE Root cause analyses
The number of root cause analyses carried out on cases of
hospital associated thrombosis
Encouraging healthy lifestyles
Encouraging healthy lifestyles – Alcohol
cessation
90% of NHS Patients seen at face to face preadmission with
their alcohol status recorded and intervention offered to 99%
those at risk
Early warning scores
EWS – compliance
Reduce clinical risk to patients by increasing compliance with
Medical Early Warning Assessments protocols through
delivery of training programme
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2.2.5 Statements from the Care Quality Commission (CQC)
Boston West Hospital is required to register with the Care Quality Commission
and its current registration status on 31st March is registered without conditions.
Boston West Hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
2.2.6 Data Quality
It is important to have safe practice and process to underpin healthcare care.
Without excellent data quality we are not able to deliver safe effective care or
demonstrate that it is delivered. The annual audit program is inclusive of data
quality ensuring that any issues are identified and addressed. It is important that
VTE compliance is monitored and that data is entered correctly because this
informs our practice and informs patients how safe our service is. This year a
VTE post operative re assessment addition was added to operation notes. This
prompts clinicians to review a patient’s risk of clot post operatively in the event
that their clinical condition has changed and the risk of clot has increased as a
result.
Boston West Hospital will be taking the following actions to improve data quality.
Develop a local quarterly RAG rated report broken down by consultant
demonstrating infection rates versus activity
Monitor compliance of post operative VTE documentation by consultants
Improve the processes around data collection and submission in relation to
PROMS
NHS Number and General Medical Practice Code Validity
Boston West Hospital 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 and
0% for accident and emergency care (not undertaken at our hospital).
Quality Accounts 2013/14
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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
Boston West Hospital was not subject to the Payment by Results clinical coding
audit during 2013/14 by the Audit Commission.
Quality Accounts 2013/14
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2.2.7 Stakeholders Views on 2013/14 Quality Account
NHS South Lincolnshire CCG Commentary for Ramsay Boston West Hospital
Quality Account 2013/14
NHS South Lincolnshire CCG’s main priority is to ensure that services are safe and of a
high quality. The Boston West Hospital Quality Account highlights areas of service that
demonstrate high quality care using the three key areas of effectiveness, safety and
patient experience. As part of the national CQUIN for last year Boston West Hospital
achieved the introduction of Dementia Screening of patients over the age of 75 and
where necessary referred them on to appropriate care providers. The hospital used an
innovative approach to the PLACE assessments which review cleanliness, catering,
environment and the facilities provided, by empowering a patient and public forum to
influence change and give feedback on practice. Further, to enhance patient safety, a
priority for 2013/14 was the introduction of an early warning system (EWS) which
provided a structure for nurses to escalate concerns about a patient if their condition
should deteriorate.
The focus on patient experience is welcomed by the CCG and the continued drive to roll
out the Friends and Family test survey by the introduction of a new web based patient
survey means to gather patient opinion. Currently 97% of patients would recommend
Boston West Hospital to family and friends.
South Lincolnshire CCG notes that Boston West Hospital is required to register with the
Care Quality Commission and its current registration status on 31 March 2014 has no
restrictions. The Care Quality Commission has not undertaken any enforcement action
against Boston West Hospital since its registration.
South Lincolnshire CCG can verify that Boston West Hospital has reported against all the
mandated statements within the Quality Account where data is available.
In terms of performance against the CQUIN scheme for 2013/14 Boston West Hospital
fully achieved the following:
Friends and Family Test
NHS Safety Thermometer
VTE
Encouraging Healthy Lifestyles - Alcohol Cessation
EWS – Compliance
There was partial achievement of:
Dementia - Find, Assess, Investigate and Refer
The CCG endorses the areas identified for improvement for 2014/15 and the associated
initiatives as detailed within the Boston West Hospital Quality Account in particular the
focus on pain management and information about pain management at point of
discharge. The CCG notes that one of the CQUIN’s this year will continue to maintain
emphasis patient safety namely, VTE risk assessment and prevention.
Quality Accounts 2013/14
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The South Lincolnshire CCG CQUIN scheme for 2014/15 will consist of the following:
Friends and Family Test
Dementia
Safety thermometer – improvement goal falls
Pain management
National Early Warning Score – NEWS Compliance
South Lincolnshire CCG endorses the accuracy of the information presented within the
Boston West Hospital Quality Account and the overall quality programme performance
will be reviewed through the formal contract quality review process and triangulation
through patient experience surveys.
Healthwatch Lincolnshire
tbc
Health Scrutiny Committee for Lincolnshire
HEALTH SCRUTINY COMMITTEE
Statement on Boston West
Hospital's Quality Account for
2013/14
FOR LINCOLNSHIRE
This statement has been prepared by the Health Scrutiny Committee for Lincolnshire.
Progress on Priorities for 2013-14
We are pleased with the progress by Boston West Hospital on its priorities for 2013-14, in
particular its participation in the dementia screening programme and the outcomes of the
Patient-Led Assessment of the Care Environment.
Priorities for 2014-15
We support Boston West Hospital's priorities for 2014-15, and look forward to progress on these
priorities leading to improvements in the patient experience and patient safety.
Quality Accounts 2013/14
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Engagement with the Health Scrutiny Committee
Three members of Health Scrutiny Committee visited Boston West Hospital in 20 January 2014.
They found the visit a positive experience and the member of the Committee who wrote the
report of the visit said: "The hospital is a happy, clean, well run environment where I would feel
very happy to receive treatment."
The report is set out below:
"Sue Harvey, the Matron, and Heather Emmerson, the Liaison Officer, gave us a guided
tour of the hospital and explained that Ramsay Health Care had taken over the hospital
from Capio, and changed the name last year to Boston West Hospital.
Ramsay Health Care have hospitals in Australia, France and a sister
hospital (The Fitzwilliam) in Peterborough, with others across England.
They offer NHS-funded and private health care.
Day Case only services are commissioned by the CCGs and NHS, 95%
by the ‘Choose and Book’ system.
They offer consultant-delivered care, short waiting times (4 – 6
weeks), and a choice of time and date.
All patients are assessed to make sure they are suitable for day case
surgery. Not all patients are suitable.
If necessary a patient could be transferred to Pilgrim Hospital for
critical care – one case in the past five years.
Boston West mainly performs orthopaedic and ophthalmic surgery, but
also offers some urology, gynaecology and pain management services.
Boston West also provides General Surgery and Gastroenterology
Services.
MRI – diagnostic imaging is on a Friday.
Consulting Rooms
Hand sanitisers are available and are used by staff and patients,
outside every door.
There are five outpatient consulting rooms and one nurse in
attendance.
Nurses room at end of corridor.
Reasonably bright and comfortable, two of the five rooms have a
window.
The consultant and staff on duty seemed happy with the system.
Autoclave (Sterilising Unit)
Surgical items from both the Fitzwilliam and Boston West are sterilised
on site.
All items are scanned in and can be tracked from source.
All items are sterilised, packed and then steamed at high temperature.
Distributed back to source and good for up to a year if unopened.
Surgery
Quality Accounts 2013/14
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200 – 250 patients per month receive services from the day hospital.
Two admission bays.
Surgery is on a rolling basis, patients arriving every half hour or so.
Patient lockers accessible from two sides.
There is one operating theatre, with full time anaesthetist in
attendance.
All procedures follow the NICE and day surgery guide lines.
2 bed recovery bay with one to one nursing.
45 minutes – 1 hour in recovery bay, then into a recliner prior to
leaving.
24 hour help line available once a patient has been discharged.
A knee surgery patient: in by 7.30am, in theatre by 8am, home before
11am.
Staffing
Staff are recruited from
Staff are able to gain
Health.
They have a customer
Gold,
Assessment forms are
journey.
the area.
wide experience and progress within Ramsay
excellence award system, Bronze, Silver and
given to patients, to help assess the patient
General Comments
The hospital is a happy, clean, well run environment where I would feel
very happy to receive treatment.
There are well qualified experienced surgeons and staff."
Achievements
We congratulate Boston West Hospital on the following achievements during the last year:
the high cleanliness rating from Patient-Led Assessments of the Care
Environment;
the absence of any MRSA infection
the introduction of a new procedure in colo-rectal surgery; and
the 97% patient satisfaction score.
Conclusion
We are grateful for the opportunity to make a statement on Boston West Hospital's Quality
Account. We congratulate the Hospital on its improvements and achievements during the last
year. The Committee would like to continue maintaining links with the Hospital during the
coming year.
Quality Accounts 2013/14
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Patient and Public Involvement Group Representative – Mr Joe Nash
It is very difficult to write this without giving a ‘too good to be true’ veneer. I am
really impressed by everyone’s friendly professional attitude and the personal
service where one sees the same few people on every visit.
I am involved with the patient participation group because Boston West Hospital
asked me and the hospital does come across as genuinely wanting to give a
service which is second to none. That can’t be achieved without asking patients,
people like me, for their input, ideas and suggestions for improvement. I am very
happy to put my 18 years experience of poor health and as wheelchair user to
some use.
Whatever we do for a living, we know full well that after years of undertaking the
same tasks we can get ‘casual’ with some of the repetitive parts of our work.
Health professionals are no different. The Ramsay staff however don’t want to
fall into that trap and we, the Patient Participation Group, are here to see the
hospital though the patients’ eyes and keep patient perspective at the fore front of
care at Boston West.
I don’t think that enough people are aware of patient choice and the fact they can
choose to have NHS treatment at hospitals like Boston West which was why I
was so pleased that the hospital Liaison Officer was happy to come out and talk
to my stroke support group.
Quality Accounts 2013/14
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Matron, Sue Harvey
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.
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
Quality Accounts 2013/14
Page 34 of 52
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
Page 35 of 52
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.
3.1 The Core Quality Account Indicators
Mortality
Mortality:
Expected
Deaths:
Period
Best
2012/13
RKE
0.65
RXL
2013/14
RKE
0.63
RBT
Period
Best
Apr12 RBA
Mar13
Jul12 RBA
Jun13
Worst
Average
Period
Boston West
1.17
Eng
1
2012/13
NVC27
0
1.15
Eng
1
2013/14
NVC27
0
Average
Period
Boston West
Worst
0.1
RWH
44.0
Eng
20.4
2012/13
NVC27
0.0
0.0
RWH
44.1
Eng
20.2
2013/14
NVC27
0.0
Boston West Hospital considers that this data is as described for the following
reasons;
Death is rare and as illustrated below the national average. Although there
have never been any deaths at Boston West Hospital since the hospital
opened 9 years ago. However, should any death occur, it would be
investigated and reported the CQC and CCG.
Quality Accounts 2013/14
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PROMS
Period
PROMS:
Apr12
Mar13
Apr13
Sep13
Hernia
Period
Apr12
Mar13
Apr13
Sep13
PROMS:
Veins
Best
-
Worst
NT415 0.157 NVC27 0.015
Eng 0.085
RTG
Eng 0.086
0.138 RNA
Best
-
Average
0.019
Worst
Period
Apr12
Mar13
Apr13
Sep13
Average
RV8
5.14
NT350
-15.92
Eng -8.374
RTD
-9.74
RLN
-10.52
Eng -9.46
Period
Apr12
Mar13
Apr13
Sep13
Boston West
-
NVC27 0.015
NVC27 *
Boston West
-
NVC27 *
NVC27 *
Boston West Hospital considers that this data is as described for the following
reasons;
Patient engagement
Poor process
Low volumes
Boston West Hospital has taken the following actions to improve this;
Redesigned the process
Engaged and communicated with patients
Weekly audit of the submissions
Readmissions
Period
Best
Worst
2010/11
RF4
0.0
RYR
2011/12
RF4
0.0
RYR
Average
Period
Boston West
15.8
Eng
11.04
2012/13
NVC27
0
15.8
Eng
11.08
2013/14
NVC27
0
Boston West Hospital considers that this data is as described for the following
reasons:
Quality Accounts 2013/14
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As a day case hospital, any unplanned emergency readmissions would
present to the local Trust Hospital, therefore there are no readmissions as
such to Boston West Hospital. We are aware of any readmission by the
patient phoning the 24 hour emergency nurse helpline phone with a
problem requiring the nurse to advise A&E attendance. These patients are
then followed up to learn of the outcome. These known readmissions are
reported on our Riskman incident reporting system and reviewed by our
clinical governance committee. There have been 6 known readmissions in
2013 14, which equates to 0.23%.
This readmission rate is below average this could be attributed to good
clinical care and treatment. Patients are provided with information at the
point of discharge about after care services.
Boston West Hospital will continue to provide patients with aftercare advice and
encourage patients to return when clinically indicated.
Responsiveness
Responsiveness: Period
Best
Worst
Average
Period
Boston West
to personal
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC27
NA
needs
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC27
NA
Boston West Hospital considers that this data is as described for the following
reasons;
The scores were taken from the CQC inpatient survey and therefore we
were unable to participate in this survey due to being a day case surgery
hospital. Feedback on responsiveness to patients needs is gathered from
our external Qa Research survey and scores remain high. Scores of
patient responsiveness for our CQUIN in 2012/13 were taken from 5 very
similar questions in our external survey to those of the DoH inpatient
survey, agreed with CCG commissioners. The scores ranged from 98% –
100%
Boston West Hospital will continue to listen and act upon patient feedback to
maintain a high responsiveness to patient’s needs.
Quality Accounts 2013/14
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VTE Assessment
VTE
Period
Assessment:
13/14
Q3
13/14
Q4
Best
Worst
Average
Period
Several 100% NT244 63.2% Eng 95.8%
Several 100% NT205 67.0% Eng 96.0%
13/14
Q3
13/14
Q4
Boston West
NVC27 99.7%
NVC27 100%
Boston West Hospital considers that this data is as described for the following
reasons;
The scores are higher than the national average
The scores consistently improve year upon year
Boston West Hospital has implemented VTE post operative re assessment of
VTE risk to prompt clinicians post operatively. Any changes in risk as a result of
surgery are documented and changes made to treatment accordingly.
C. Diff rate
C. Diff rate:
per
100,000
Period
Best
Worst
2012/13
Several
0 RNA
bed days
2013/14
Several
0 RVW
Average
Period
Boston West
58.2
Eng
22.2
2012/13
NVC27
0.0
30.8
Eng
17.3
2013/14
NVC27
0.0
Boston West Hospital considers that this data is as described for the following
reasons;
The scores reflect consistent practice in pre assessment
The scores reflect good infection and prevention control practices
Boston West Hospital intends to continue its current practice to maintain a score
of 0.
Quality Accounts 2013/14
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F&F Test
F&F Test:
Period
Best
Worst
Average
Jan-14
Several 100 RPA02
27 Eng
Feb-14
Several 100 RPA02
18 Eng
Period
Boston West
73
2012/13
NVC27
96.72
73
2013/14
NVC27
96.54
Boston West Hospital considers that this data is as described for the following
reasons;
The hospital places great emphasis on patient satisfaction and the friends
and family question is encompassed within this. This is reflected in the
score and Boston West Hospital has a higher than the national average
scores as a result.
Boston West Hospital intends to continue its good work and aim to increase its
percentage further in 2014/15.
3.2 Patient Safety
We are a progressive hospital and are 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
Boston West Hospital 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.
Quality Accounts 2013/14
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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:
Boston West Hospital has a dedicated Infection control nurse who is responsible
for delivering an annual strategy of infection control. The annual plan is inclusive
of a training, audit, surveillance and screening programme. The graph below
illustrates a slight decrease in infection rates, this may be due to lessons learnt
from infections and taking steps to avoid similar infections by implementing
standardised antibiotic prophylaxis prescribing protocols for certain urological and
general surgery procedure types. Infection is reported across all departments,
including patients that present in the primary care. Infections are reported if there
is a positive swab result or in the event of signs of an infection when a swab has
not necessarily been taken. This is done through our surgical surveillance
programme and ensures that we capture all data.
Infection Rates
Infection Rates
(percentage of Admissiosns)
2.5
2
1.5
1
0.5
0
2011/12
2012/13
2013/14
Boston West Hospital
Quality Accounts 2013/14
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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 Boston West Hospital, 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.
In 2013 members of Boston West Hospital Patient & Public Involvement Forum
Committee formed part of our PLACE inspection team, along with Heath Watch
representation.
Our results are illustrated below:
Cleanliness
Food
98.72%
95.75%
85.42%
Green = National average
Privacy, Dignity &
Wellbeing
Condition, Appearance &
Maintenance
60.00%
82.69%
88.90%
88.78%
Blue = Boston West Hospital score
Quality Accounts 2013/14
Page 42 of 52
Privacy and dignity was scored at 60% by the inspectors. This is due to a number
of the measures being not applicable at Boston West Hospital with their being no
overnight beds or patient bedrooms. In the measures that were applicable we
scored well, apart from an issue that was highlighted regarding private
conversations with patients in their admission bay / pod. We have a process in
place to offer a private room for those conversations.
We do not have catering facilities on site, so the food section was not applicable.
There were a number of areas in need of touch up decoration. A planned
maintenance programme is in place to ensure the areas highlighted will be
subject to decoration over the months following our PLACE inspection. Staff
have taken ownership of information boards in all areas to ensure they remain
tidy and up to date.
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; this awareness then naturally extends to safeguarding patient safety.
Our record in workplace safety as illustrated by Accidents per 1,000 Admissions
demonstrates the results of safety training and local safety initiatives.
Period
Best
Worst
Average
2011/12
RP6
2.6
TAJ
84.4 Eng
2012/13
RRF
2.0
RAT
85.6 Eng
Period
Boston West
13.5
2012/13
NVC27
8.77
14.8
2013/14
NVC27
9.61
Relative to the national average, Boston West Hospital is below the national
average which is due to:
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.
Local safety initiatives have included integration of dry mopping policy,
increased awareness of how to report, and of review risk assessments.
Quality Accounts 2013/14
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3.3 Clinical effectiveness
Boston West Hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Boston West Hospital
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 incidences of returns to theatre are
normal. The value of the measurement is to detect trends that emerge in relation
to a specific operation or specific surgical team. Our rate of return is very low;
consistent with our track record of successful clinical outcomes.
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3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and Department of Health (DH) organisations occurs as required and
according to Ramsay and DH policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
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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
Manager whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROM’s 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
to 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
Quality Accounts 2013/14
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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.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
97.0
99.0
2012/13
2013/14
20
0
Boston West Hospital
As illustrated in the above graph our patient satisfaction scores remain very high.
The activity at Boston West hospital has grown year on year and ensuring that we
improve patient satisfaction scores is a key priority. An on- going in house training
programme on customer service is delivered, and staff are recognised through a
reward programme for exceptional levels of customer service.
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3.4 Boston West Hospital Case Studies
1) New Service - Transanal Haemorrhoidal De- Arterialisation (THD)
Haemorrhoids more commonly known as piles affects 3 in 4 people and can
affect anyone at any age often causing discomfort and pain. Transanal
Haemorrhoidal Dearterialisation (THD) was introduced at Boston West Hospital as
an alternative to the traditional haemorrhoidectomy . Transanal Haemorrhoidal
De-arterialisation involves ligating branches of the superior rectal artery and a
repair of the rectal prolapse by plication / mucopexy.
Selecting THD as the primary treatment option for haemorrhoids will provide the
patient with a minimally invasive procedure which leaves no open wounds, no
need for any dressing, very little discomfort and a quick return to work and normal
activities, offering important social benefits. It is a procedure that is scientifically
designed to deal with the principle cause of the haemorrhoids, their main blood
supply.
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In February 2014, Mr Rao,
Colo-Rectal Consultant
Surgeon, performed the first
THD operations here at Boston
West Hospital with excellent
results.
The operation is performed under a general anaesthetic using an endo-anal
device under ultrasound guidance. The haemorrhoid arteries are located and tied
off which leads to shrinkage of the piles. It involves no cutting of tissue and is
performed under day case conditions.
The success rate is over 90% and can be performed again if required. Patient
feedback with regard to this treatment has been positive and we will continue to
develop our services with the overall aim of providing excellent clinical outcomes
and excellent patient experience.
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2) Making Every Contact Count – (MECC)
Lincolnshire was able to
facilitate
a
partnership
between Boston West Hospital
and MECC (Making Every
Contact
Count)
for
Lincolnshire patients.
MECC were able to provide
training for our staff who in
turn now share this new
knowledge with patients during
pre assessment clinics and
admissions. This enabled
patients to access a wide variety of services to promote healthier life styles,
engage them in social activities reducing social isolation and allow MECC to
collate data on health and well being in our area.
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Appendix 1
Services covered by this quality account
RAMSAY HEALTHCARE UK OPERATIONS LIMITED
Boston West Hospital
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Colorectal Medical
Colorectal Surgical
Complex Hand Clinic
Diagnositc Endoscpy Clinic
Endoscopy Lower GI Clinic
Endoscopy Upper GI Clinic
Gastroenterology Clinic
General Gynecology Clinics
Gynecology Clinic Female Consultant
Cataract Clinic
Foot & Ankle Clinic (Excl Apply)
Hand & Wrist Clinic
Hip & Knee Clinic
Knee Arthroscopy Clinics
Pain Management Clinic
Shoulder & Elbow Clinic
Shoulder Only Clinic
Hernia Repair Clinic
General Urology Clinic
Hip Arthroscopy Clinic
Rectal Bleeding Clinic
Varicose Vein Clinic
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Appendix 2
– Clinical Audit Programme
2013/14.
Each arrow links to the audit to be completed in each month.
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Appendix 3
Glossary of Abbreviations
ACCP
AIM
ALS
CAS
CCG
CQC
CQUIN
DDA
DH
EVLT
GP
GRS
HCA
HPD
H&S
IHAS
IPC
ISB
JAG
LINk
MAC
MRSA
MSSA
NCCAC
NHS
NICE
NPSA
ODP
OSC
PEAT
PPE
PROM
RIMS
SAC
SMT
STF
SUI
TLF
ULHT
VTE
American College of Clinical Pharmacology
Acute Illness Management
Advanced Life Support
Central Alert System
Clinical Commissioning Group
Care Quality Commission
Commissioning for Quality and Innovation
Disability Discrimination Audit
Department of Health
Endovenous Laser Treatment
General Practitioner
Global Rating Scale
Health Care Assistant
Hospital Patient Days
Health and Safety
Independent Healthcare Advisory Services
Infection Prevention and Control
Information Standards Board
Joint Advisory Group
Local Involvement Network
Medical Advisory Committee
Methicillin-Resistant Staphylococcus Aureus
Methicillin-Sensitive Staphylococcus Aureus
National Collaborating Centre for Acute Care
National Health Service
National Institute for Clinical Excellence
National Patient Safety Agency
Operating Department Practitioner
Overview and Scrutiny Committee
Patient Environmental Action Team
Personal Protective Equipment
Patient Related Outcome Measures
Risk Information Management System
Standard Acute Contract
Senior Management Team
Slips, Trips and Falls
Serious Untoward Incident
The Leadership Factor
United Lincolnshire Hospitals Trust
Venous Thromboembolism
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Boston West Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
01205 591860
http://www.bostonwesthospital.co.uk
Quality Accounts 2013/14
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