Euxton Hall Hospital
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 2010/11 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
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Euxton Hall 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)
Quality Accounts 2013/14
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Introduction to our Quality Account
This Quality Account is Euxton Hall Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It reports on the period 1st
April 2013 to 31st March 2014 and presents our achievements in terms of clinical
excellence, effectiveness, safety and patient experience. It also 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.
Quality Accounts 2013/14
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Part 1
1.1 Statement on quality from the General Manager
“Ramsay Health Care UK is committed to establishing an organisational culture that
puts the patient at the centre of everything we do. As General Manager of Euxton
Hall Hospital, I am passionate about ensuring that high quality patient care is our
number one priority. This relies not only on excellent medical and clinical delivery but
also upon continued commitment to driving improvement in clinical outcomes.
Ramsay Health Care UK has a structured clinical governance framework that
enables continual review of performance. This allows us to drive improvements for
the benefit of all patients
This Quality Account not only accurately documents through our data our
achievements in delivering excellent services, but also highlights the areas that we
need to improve upon.
Our Quality Account is information for our patients and commissioners to assure
them that we are committed to sharing our progressive achievements year on year.”
David Winters
General Manager
Euxton Hall Hospital
Quality Accounts 2013/14
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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.
David Winters
General Manager
Euxton Hall Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Jan Ledward, Chief Officer, NHS Chorley and South Ribble Clinical
Commissioning Group
Healthwatch
A copy of the Quality Accounts has been sent to Healthwatch
Dr Ian Drake, Consultant Gastroenterologist, Chairman of Euxton Hall Medical
Advisory Committee (MAC),
Mr Stefan Andrejczuk, Regional Director Ramsay Health Care UK,
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Welcome to Euxton Hall Hospital
Euxton Hall Hospital is one of Lancashire’s leading private hospitals situated on the
outskirts of Chorley but close to Preston and Wigan.
The facility offers 32 beds all with en suite facilities to ensure complete privacy. Each
room includes a digital television and telephone. Our private patients are
automatically allocated a Premium Care single room with en suite facility, they are
also provided with Molton Brown toiletries, a newspaper of their choice and an à la
carte menu.
The hospital boasts two fully equipped ultra clean air theatres, an endoscopy and
small treatment room and by investing in advanced medical technology offers a wide
range of treatments and services.
Euxton Hall Hospital specialises in orthopaedics procedures offered such as
arthroscopy, hip, knee replacement and upper limb surgery and offers rapid access
to Breast Care services due to the X-ray and radiology facilities on site.
Euxton Hall Hospital offers the latest physiotherapy support in a purpose built sports
injury centre. The hospital has the latest Cybex Isokinetic equipment and offers
electrotherapy, continence clinic, back pain clinic, podiatry, personal training,
aromatherapy, reflexology and acupuncture.
As well as this we offer
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Cardiology
Cosmetic Surgery
Dermatology
Diagnostics
ENT
Gastroenterology
General Surgery
Gynaecology
Neurology
Pain Management
Physiotherapy
Rheumatology
Speech Therapy
Urology
Quality Accounts 2013/14
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With 105 registered Consultants and a workforce of approximately 125 contracted
staff and a 24 hour RMO, Euxton Hall Hospital provides fast, convenient,
effective and high quality treatment for patients (subject to certain exclusion
criteria), whether medically insured, self-pay, or from the NHS.
In addition Euxton Hall Hospital has established a successful outreach clinic, The
Gathurst Consulting rooms offering both Gynaecological and General services to
the people of Wigan without the need to travel. The hospital is currently
investigating the possibility of opening a second outreach clinic.
Each year Euxton Hall Hospital chooses one charity to support for the year and
last year it was Hand on Heart – who provides life saving defibrillators to schools.
During 2013 enough money was raised to donate one to each of the four local
primary schools in Euxton
Part 2
2.1 Quality priorities for 2013/2014
On an annual cycle, Euxton Hall 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.
2.1.1 A review of clinical priorities 2013/14 (looking back)
Patient-led Assessments of the Care Environment (PLACE) last year
replaced the annual Patient Environment Action Team (PEAT) audit.
PLACE is a patient led audit that will have an assessment team that consists of
50% patients. The audit includes all internal and external areas of the hospital
only excluding operating theatres. The audit is divided by each department of the
hospital and assesses the standard of cleanliness and general upkeep of the
building and grounds. It also evaluates the standard of the food being served to
patients, ensuring that all dietary requirements are met. The scoring system
employs a system whereby areas are given a ‘Pass’, ‘Fail’ or ‘Qualified Pass’.
Euxton Hall Hospital’s PLACE audit took place on 16th May 2013 and the
following is an overview of the scores achieved:
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Cleanliness – 92.54%
Food – 95.43%
Privacy – 90.32%
Condition – 84.25%
Clinical Documentation Audits – Remained a priority in all areas with a
corporate Ramsay focus In 2013/14 on theatre safety checks and Physiotherapy
documentation checks. The team achieved full completion of the Ramsay
corporate audit programme.
Surgical Safety Checklist - There have been no ‘Never Events’ at Euxton Hall
Hospital in the period and an audit of compliance maintains a key focus with a
monthly audit of WHO safety checklists.
VTE Assessment – There has been an improvement in compliance with
completion of VTE documentation for patients where appropriate. Support from
the Group Medical Director included a presentation to the Medical Advisory
Committee on clinician responsibilities in the completion of VTE risk
assessments. Quarterly audit scores have demonstrated an improvement and
compliance remains a focus across the whole of the Ramsay Group.
Infection Control – We have had no reportable infections and no outbreaks
reported in the period. We continue to screen patients for MRSA in line with NHS
England guidelines and training for staff on hand hygiene is mandatory. The
infection control team have worked to improve standards in environmental
cleaning in the period with the Clinical Lead leading quarterly environmental
audits in the period. Internal audits demonstrate that compliance remains high.
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Incident Reporting – The Ramsay Group risk management system ‘Riskman’ is
used to report clinical incidents, health and safety incidents, staff well-being and
absence and patient feedback. Additional training has been given to all staff to
ensure timely, comprehensive and effective reporting and compliance with
reporting has been good.
Competency Training – Competency assessment tools have been completed
for all clinical staff appropriate to their area of practice.
Preoperative Assessment – The preoperative assessment policy is followed
and provides safe and efficient assessment of all patients following their
outpatient clinic appointment. Patients complete a medical questionnaire which is
reviewed by nursing staff to determine the level of preoperative assessment
required to ensure the appropriate needs of the patient are met.
Patient Satisfaction Survey – The hospital’s web-based satisfaction survey has
been in place since February 2013 with a response rate of 46.6% at the end of
March 2014. The average satisfaction rate for the year was 94.9%. We have
gained a 4.5 star rating on the NHS Choices website following patient feedback
posts describing their positive patient experiences.
Patient Reported Outcome Measures Studies (PROMS) – the hospital has
encouraged patients to participate in PROMs surveys to monitor patient assessed
outcomes of surgery regarding varicose veins, hip and knee replacement and
inguinal hernia. Response rates have improved throughout the year.
Information Security – Euxton Hall Hospital has achieved the information
security accreditation ISO 27001. The process of raising the importance of data
protection and information security has been successful and has been fully
embraced by our staff.
Local CQUINS
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Smoking Cessation - The hospital identified and recorded smoking status of
all admitted patients and recommended appropriate intervention. The hospital
achieved a compliance rate of 100% for 2013/14.
Alcohol Awareness – The hospital identified and recorded alcohol use of all
admitted patients and recommended appropriate intervention. The hospital
achieved a compliance rate of 100% for 2013/14.
Quality Accounts 2013/14
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National CQUINS
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Friends and Family Test – The hospital undertook Friends & Family testing
with both inpatient and daycase patients. In the most recent quarter
(Jan/Feb/March 2014) the hospital received an average response rate for
daycase patients of 41.3% with an average of 96% rate for ‘extremely likely to
recommend’. The average response rate for inpatient patients was 46% with
an average of 100% rate for ‘extremely likely to recommend’.
The hospital undertook Friends & Family testing with staff in the period,
achieving a 51% response rate and a 98% rate for ‘Extremely Likely or likely
to recommend’.
VTE Risk Assessment – The hospital was set a compliance target of 97%,
for the period compared to the national target of 95%, and continuously
achieved 99% or above for the last 12 months.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Clinical priorities for 2014/15 will focus on: Patient Safety, Clinical Effectiveness,
and Patient Experience.
Patient Safety;
The NHS Safety Thermometer focuses on the reduction of patient harm. The
power of the NHS Safety Thermometer lies in allowing frontline teams to measure
how safe their services are and to deliver improvement locally. This CQUIN
requires the hospital to undertake a survey on one day per month, of all
appropriate patients, using the NHS Safety Thermometer tool, to collect data on
pressure ulcers, falls, new venous thromboembolism (VTE) and urinary tract
infection (in patients with a catheter). Euxton Hall has been 100% compliant with
data submission and will continue to submit this data.
Surgical Safety Checklist – ‘Never Events’ are serious, largely preventable
patient safety incidents that should not occur if the available preventative
measures have been implemented as standard practice. Monthly audits will
continue to be undertaken with an expectation of 100% compliance. Where this is
not achieved actions plans will be developed and responsibilities communicated
with the teams. Briefing and debriefing sessions after all operating sessions
continue and give opportunity for shared learning, recommendations for future
practice and aim to encourage autonomy for all members of the team.
Compliance will be monitored by regular audit and reviewed by the hospital’s
Clinical Governance and Medical Advisory Committees.
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VTE Assessment - A VTE risk assessment is completed for patients according to
CM 001 VTE policy and requires consultants to review and to complete prior to
procedure. This remains a focus at Euxton Hall Hospital with quarterly audits
completed to maintain standards. Results are reviewed and actions determined at
the hospital’s Clinical Governance and Medical Advisory Committees.
Staffing – To ensure adequate numbers of skilled staff are available to care for
our patients staff rosters are prepared in advance. An electronic rostering tool
‘Allocate’ was introduced in December 2013 taking into account the necessary
skill mix for the scheduled patient activity.
In addition, the Ramsay Academy provides learning and development
opportunities for all staff and Ramsay’s Management Development Framework
provides opportunities for our leaders to develop skills and knowledge. We
recognise the value of the Health Care Assistant (HCA) within Ramsay and
competency assessments are in place to allow all HCAs to reach their full
potential.
Clinical Effectiveness;
The Advancing Quality (AQ) Programme is an innovative quality improvement
scheme that aims to improve the quality of healthcare and the patient experience
of healthcare across the North West, with the focus for the hospital being hip and
knee replacement surgery. Advancing Quality works with clinicians to provide
hospitals with a set of quality standards which define and measure good clinical
practice. Each measure should be delivered to every patient to ensure they
receive the highest standard of care in hospital. AQ is based on simple
evidence–based interventions as agreed by clinicians that are driven in tandem
by clinicians and managers to:
 Save lives
 Improve the quality of life for patients
 Facilitate CCG assurance frameworks
 Incentivise improvement in quality to international levels
 Achieve value for money
 Creates a system that collaborates
The CQUIN will measure the proportion of patients that received all of the
relevant interventions and are therefore a measure of ‘perfect care’. The goal for
this measure is to reflect high quality of care but not necessarily 100% attainment
for each measure. The underlying clinical process measures for Hip & Knee
Replacement in 14/15 are:
 Prophylactic antibiotic received within one hour prior to surgical incision.
Quality Accounts 2013/14
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Prophylactic antibiotic selection for surgical patients (policy to be provided
at external audit).
Prophylactic antibiotics discontinued within 24 hours after surgery end
time.
Recommended Venous Thromboembolism prophylaxis ordered.
Appropriate Venous Thromboembolism prophylaxis administered within 12
hours of surgery end time.
Appropriate VTE duration post-surgery (information only).
Patient Reported Outcome Measures (PROMs) assess the quality of care
delivered to NHS patients from the patient perspective. Currently covering four
clinical procedures, PROMs calculate the health gains after surgical treatment
using pre- and post-operative surveys. PROMs have been collected by all
providers of NHS-funded care since April 2009, and provide an indication of the
outcomes or quality of care delivered to NHS patients. We will continue to monitor
patient response rates as part of a local CQUIN indicator with a graduated
quarterly target to achieve greater than 80% compliance by quarter four of
2014/15.
Maintaining Endoscopy Standards is a priority for Euxton Hall for 2014/15 and
our JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation
inspection is due later in 2014. Biannual submission to GRS (Global Rating
Score) continues, enabling us to assess how well we provide a patient-centred
service.
Patient Experience: The Friends and Family Test aims to improve the
experience of patients in line with the NHS Outcomes Framework. The friends
and family survey now includes an audit of staff opinion as well as in-patient and
day-case patients, and will also be rolled out to include the out-patient
experience.
The Friends and Family Test will provide timely feedback from patients about
their experience and results from this survey will be reviewed and shared with the
hospital departments. The hospital has been set the national expectation of a
30% response rate across all hospital areas.
Patient Satisfaction Survey – We will continue to encourage patients to provide
feedback using our web based satisfaction survey. ‘Hot alerts’ received following
completion of the survey will be reviewed by the General Manger and Matron and
action taken where there are areas identified for improvement. All comments
positive and negative are shared with the whole team along with a monthly
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patient satisfaction dashboard. Compliments and complaints are reviewed at the
hospital’s Clinical Governance and Medical Advisory Committees and lessons
shared with the nursing teams. We will continue to monitor posts on NHS choices
and remain committed to improving patient satisfaction.
Equality Delivery System – Euxton Hall Hospital will be one of the first private
hospitals to work on NHS England’s EDS2 initiative to ensure that the services
we provide for patients and that the working environment we provide to staff is
free of discrimination, in accordance with the nine protected characteristics under
the Equality Act 2010; age, disability, gender reassignment, marriage and civil
partnership, pregnancy and maternity, race, religion and belief, gender and
sexual orientation.
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 Euxton Hall Hospital provided NHS services across eight surgical
specialties.
Euxton Hall Hospital has reviewed all the data available to them on the quality of
care in all of these NHS services.
The income generated by the NHS services reviewed in 1st April 2013 to 31st
March 2014 represents 74.6% per cent of the total income generated from the
provision of NHS services by Euxton Hall Hospital for 1st April 2013 to 31st March
2014.
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:
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Human Resources
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Staff Cost % Net Revenue
HCA Hours as % of Total Nursing
Agency Cost as % of Total Staff Cost
Ward Hours PPD
% Staff Turnover
% Sickness
% Lost Time
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
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Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Significant Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
Quality
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Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
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2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014 Euxton Hall Hospital participated in two
national clinical audits..
The national clinical audits that Euxton Hall Hospital participated in, and for which
data collection was completed during 1st 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.
Name of audit / Clinical Outcome
Review Programme
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
% cases
submitted
93.4
61.1
The reports of these national clinical audits were reviewed by the hospital’s
Clinical Governance Committee.
Local Audits
The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Euxton Hall Hospital. 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.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Euxton Hall Hospital’s income in from 1 April 2013 to 31st March
2014 was conditional on achieving quality improvement and innovation goals
through the Commissioning for Quality and Innovation payment framework.
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2.2.5 Statements from the Care Quality Commission (CQC)
Euxton Hall Hospital 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.
Euxton Hall Hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
2.2.6 Data Quality
The hospital continues to take the following actions to improve data quality:
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Regular training to ensure staff understand the importance of accurate
data input and have sufficient technical competence
Employment of a clinical coder to improve accuracy of recording
Supporting national projects to ensure data accuracy
NHS Number and General Medical Practice Code Validity
Euxton Hall Hospital’s 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:
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99.97% for admitted patient care;
99.96 for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code:
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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).
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Clinical coding error rate
Euxton Hall Hospital was not subject to the Payment by Results clinical coding
audit during 2013/14 by the Audit Commission.
2.2.7 Stakeholders views on Euxton Hall’s 2013/14 Quality
Account
Healthwatch:
A copy of the Quality Accounts has been sent to Healthwatch
Chorley and South Ribble Clinical Commissioning Group
Ramsay Health Care Quality Accounts 2013/14
NHS Chorley and South Ribble CCG have welcomed the opportunity to comment
on the Ramsay Health Care annual quality accounts for 2013/14.
The progress that we have undertaken has been to forward the accounts to the
Joint Quality Improvement Committee (JQIC), which is a sub-committee of the
CCG Governing Body, for review and comments. Ramsay Health Care was also
invited the JQIC to present their accounts at the July Committee Meeting.
Throughout the year the CCG, in partnership with Ramsay Health Care, has
reviewed and discussed quality in terms of clinical excellence, effectiveness and
patient safety on a quarterly basis. Through these discussions and the review of
supporting evidence, it is our belief that the information contained within the
quality accounts gives an overarching view of the quality of services provided
over the last year.
It is evident from the quality accounts that Ramsay Health Care is constantly
striving to improve clinical safety and standards by utilising a systematic process
of governance which includes audit and feedback.
The CCG is pleased to recognise that the clinical priorities identified for 2013/14
have all been achieved, including:
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The first patient led assessments of the care environment (PLACE)
assessment scored highly against the four areas of cleanliness, food,
privacy and the condition of the facility.
100% compliance rate attributed to their local CQUIN targets for smoking
cessation and alcohol awareness.
National CQUIN targets demonstrated highly favourable results. At both
Fulwood Hall and Renacres, 99% of patients and 97% of staff indicated
that they would be ‘extremely likely to recommend’ the hospital when
undertaking the Friends and Family Test. These results were higher at
Euxton Hall, who demonstrated scores of 100% and 98% respectively.
Continuously achieving the compliance target of 97% for VTE Risk
Assessment.
Fulwood Hall Hospital achieved JAG (Joint Advisory Group on Gastrointestinal
Endoscopy) accreditation in 2013, which demonstrates compliance against the
four domains of clinical quality; quality of patient experience; workforce and
training. This is noted to be a priority for both Euxton Hall and Renacres
Hospitals for the coming year; the JQIC wished to note this as an excellent
achievement.
The CCG would welcome the opportunity to view evidence of such good practice
throughout the year.
Core quality account indicators remain consistently high against the national
averages, with exception of PROMS (Patient Reported Outcome Measures)
scores, which can largely be attributed to low volumes of applicable patients. The
CCG recognises that action has been taken to improve the returns rate of
PROM’s questionnaires and is pleased to see that this has been identified as a
clinical priority in 2014/15. This has resulted in the formulation of a CQUIN target
in relation to this quality measure.
Ramsay Health Care consistently maintains high levels of patient and staff
satisfaction. The CCG is also pleased to recognise that individualised responses
to patient comments are entered onto the NHS Choices website, further ensuring
commitment to high standards of patient care.
The CCG would also welcome evidence in relation to any action taken to improve
practice and patient care as a result of patient and staff feedback, thereby
demonstrating an ongoing commitment to providing evidence based, quality,
patient care.
Ramsay Health Care has identified theatre safety checks and physiotherapy
documentation checks as priorities for clinical documentation audit. The CCG
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look forward to sharing any action plans as a result of these audits in order to
provide further quality assurance in relation to service provision.
The CCG value the collaborative relationship established with colleagues at
Ramsay Health Care and look forward to continuing this close working
relationship in order to continually improve the safety, effectiveness and
experience for patients over the coming year.
Yours sincerely
Jan Ledward
Chief Officer
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Part 3
Review of quality performance 2013/2014
Statements of quality delivery
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
Page 22 of 38
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
National Mortality Rates:
Period
Best
Worst
Average
2012/13
RKE
0.65
RXL
1.17
Eng
1
2013/14
RKE
0.63
RBT
1.15
Eng
1
Euxton Hall Hospital
Period
Euxton
2012/13
NVC05
0
2013/14
NVC05
0
National Expected Deaths:
Period
Apr12 Mar13
Jul12 - Jun13
Best
Worst
Average
RBA
0.1
RWH
44.0
Eng
20.4
RBA
0.0
RWH
44.1
Eng
20.2
Euxton Hall Hospital
Period
Euxton
2012/13
NVC05
0.0
2013/14
NVC05
0.0
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PPROMs
Euxton Hall Hospital has taken action to improve the returns rate of PROMs
questionnaires and so the quality of its services, by actively involving consultants
in the PROMs process in encouraging patient participation.
Hernia repair
National PROMs:
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT415
0.157
NVC27
0.015
Eng
0.085
RTG
0.138
RNA
0.019
Eng
0.086
Euxton Hall Hospital PROMs:
Period
Euxton
Apr12 - Mar13
NVC05
0.084
Apr13 - Sep13
NVC05
*
Varicose Veins
National PROMs:
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
RV8
5.14
NT350
-15.92
Eng
-8.374
RTD
-9.74
RLN
-10.52
Eng
-9.46
Euxton Hall Hospital PROMs:
Period
Euxton
Apr12 - Mar13
NVC05
*
Apr13 - Sep13
NVC05
*
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Hip Replacement
National PROMs:
Period
Best
Worst
Average
Apr12 - Mar13
NT209
24.68
RKE
17.21
Eng
21.32
Apr13 - Sep13
NT318
25.44
RHQ
18.34
Eng
21.61
Euxton Hall Hospital PROMs:
Period
Euxton
Apr12 - Mar13
NVC05
22.354
Apr13 - Sep13
NVC05
*
Knee replacement
National PROMs:
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT219
20.37
RAP
12.46
Eng
16.01
RDE
20.09
RM1
14.32
Eng
16.74
Euxton Hall Hospital
Period
Euxton
Apr12 - Mar13
NVC05
17.699
Apr13 - Sep13
NVC05
*
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Page 25 of 38
Readmissions
National Readmissions:
Period
Best
Worst
Average
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
Euxton Hall Hospital Readmissions:
Period
Euxton
2012/13
NVC05
5.31
2013/14
NVC05
0
VTE assessment
National VTE assessment:
Period
Best
Worst
Average
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
Euxton Hall Hospital:
Period
Euxton
13/14 Q3
NVC05
99.8%
13/14 Q4
NVC05
99.8%
Euxton Hall Hospital considers that this data is as described; we monitor
compliance monthly and agree an action plan if completion rates drop below 95%
maintaining a target above the national average. Euxton Hall Hospital will
continue to audit to maintain the quality of its services.
Quality Accounts 2013/14
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C Difficile rate
National C Difficile rate:
Period
Best
Worst
Average
2012/13
Several
0
RNA
58.2
Eng
22.2
2013/14
Several
0
RVW
30.8
Eng
17.3
Euxton Hall Hospital:
Period
Euxton
2012/13
NVC05
0.0
2013/14
NVC05
0.0
Euxton Hall Hospital considers that this data is as described as there have been
no reported cases of C Difficile. Euxton Hall Hospital intends to maintain this rate
by ensuring robust infection control measures are in place.
Patient safety
National Incident Rate:
Period
Best
Worst
Average
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
Euxton Hall Hospital:
Period
Euxton
2012/13
NVC05
5.36
2013/14
NVC05
6.45
Euxton Hall Hospital considers that this data is as described, we have a low level
of patient incidents reported. Euxton Hall Hospital ensures a safe environment is
maintained with all staff undertaking training and competency assessments and a
robust audit system. All incidents and accidents are reviewed at clinical
governance, health and safety and medical advisory committee and action plans
developed and lessons learned shared.
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SUI’s Severity level 1
National SUI’s Severity level 1
Period
Jul - Sep 12
Oct11 Sep12
Best
Worst
Average
NA
NA
NA
NA
NA
Eng
11,563
Euxton Hall Hospital
Period
Euxton
2012/13
NVC05
2.9%
2013/14
NVC05
0.0%
Euxton Hall Hospital considers that this data is as described, there has been no
level 1 severity incidents reported in the last 12 months.
* Volumes were too low to be reported.
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Page 28 of 38
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
Euxton Hall 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.
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:
The dedicated infection control link nurse provides mandatory training in hand
hygiene to all staff and completes a hand hygiene training session during the staff
induction day for all new staff.
Hand hygiene awareness days are led by the infection control link nurse involving
staff, patients and visitors and information in waiting areas.
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The infection control nurse reviews and completes a root cause analysis of
confirmed infections to determine any possible trends with results being
presented at our quarterly infection control committee meetings. There have not
been any trends identified in the period. As can be seen in the graph below our
infection control rate has increased over the last year due to the improved
monitoring and reporting process employed by our dedicated infection control
nurse. However this has been reviewed by our consultant microbiologist and
rates remain below the national average.
Infection Rates
Infection Rates
(percentage of Admissiosns)
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2011/12
2012/13
2013/14
Euxton Hall Hospital
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 Euxton Hall 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.
2013 PLACE results:
Cleanliness - 92.54%
Condition, Appearance and Maintenance - 84.25%
Food - 95.43%
Privacy, Dignity and Wellbeing - 90.32%
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An action plan was compiled in conjunction with a refurbishment plan to rectify some
of the low scores for general maintenance. Similarly a review of clinical equipment
i.e. trolleys was carried out and purchased where required.
As a day case facility patients did not have access to the internet this reflected a low
score for privacy and dignity and has since been rectified. An active maintenance
programme was introduced to ensure the condition and maintenance of the facilities
is maintained to a high standard.
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.
3.3 Clinical effectiveness
Euxton Hall Hospital 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.
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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.
Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.5
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Euxton Hall Hospital
Euxton Hall Hospital continues to have a very low return to theatre rate as a
percentage of overall admissions.
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.
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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
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 48 hours of receiving them so that a response can be made to the
patient as soon as possible.
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Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
99.6
95.0
20
0
2012/13
Euxton Hall Hospital
2013/14
Please note a change of satisfaction survey in early 2013 means the data year on
year is not comparable.
3.4 Euxton Hall Hospital Case Study
During the latter part of 2013 a working group was established to look into how
Euxton Hall Hospitals private service could be improved. As an outcome from
this group it was decided that to evolve and improve the service a Private Patient
Account Manager would be piloted.
The role would be responsible for coordinating all aspects of the private patients
pathway from initial enquiry through to post discharge and would be at hand
should the patient require any assistance during this time.
The role was piloted for four months and the feedback was extremely positive for
the service that was received.
This is a role that will be developed in 2014 to fit into the existing roles within the
hospital.
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3.5 Patient Feedback (Received via Friends & Family January 2014)
“Attitude of all carers was friendly and professional. I felt very safe in their hands. Thank
you.”
“The hospital is very clean and presentable. The staff are very friendly making the place
a very relaxed environment.”
“Doctors and nurses very helpful and pleasant. Everything explained really well. Rooms
were clean and comfortable and very private. All in all a very extremely satisfactory
experience.”
“Speed, courtesy and privacy - all excellent. Lovely helpful nursing staff.”
“Excellent facilities, excellent privacy, wonderful nurses, procedure performed very
quickly, my comfort considered during procedure.”
“Fast, efficient and very caring. I was looked after very well.”
“Very helpful and caring. Would recommend to friends and family.”
“The whole experience was fabulous. I was a very nervous patient but the surgeon,
anaesthetist and nurses were all fabulous. Thank you. Very happy!”
“Good service and information.”
Excellent staff with excellent bedside manner. Couldn't do enough to make me feel
comfortable.
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Appendix 1
Services covered by this quality account
Services Provided
Treatment of
Disease,
Disorder
Or injury
Cosmetics, Dermatology,
Ear, Nose and Throat (ENT),
General surgery,
Gynaecological,
Orthopaedic, Physiotherapy,
Rheumatology, Sports
medicine, Urology, Spinal,
Pain Management
Peoples Needs Met for:
All adults 18 yrs and over
All adults 18 yrs and over excluding:




Surgical
Procedures
Breast surgery, Cosmetics,
Day and Inpatient Surgery,
Ear, Nose and Throat (ENT),
Gastro-enterology, General
surgery, Gynaecological,
Orthopaedic, Pain Control,
Podiatry, Urology, Spinal,
Vascular








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.
Diagnostic
and
Screening
Imaging services,
Phlebotomy, Urinary
Screening and Specimen
collection.
All adults 18 yrs and over
Quality Accounts 2013/14
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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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Euxton Hall 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:
David Winters
General Manager
Euxton Hall Hospital
Euxton, Chorley
Lancashire, PR7 6DY
01257 276 261
www.euxtonhallhospital.co.uk
Quality Accounts 2013/14
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