2013/14

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 2012/13 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
3.6 Patient Feedback
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits

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 thousands of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning
Groups, NHS Trusts and NHS referral management and triage services.
“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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This Quality Account is Fulwood Hall Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It reports on the period 1 st
April 2013 to 31 st
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, developed by our Corporate Office, summarised and reviewed quality activities across every hospital within Ramsay Health Care UK.
It was recognised tha t this didn’t provide enough in-depth information for the public and for 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 Groupwide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.
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Fulwood Hall Hospital, established in 1986, has become an integral part of NHS healthcare provision in Lancashire, particularly since its participation in delivering the
E05 Lancashire and Cumbria Elective Surgery Agreement between 2007-2012.
Today the hospital continues to deliver high quality care under Contract from local
Clinical Commissioning Groups and a key reason for the hospital’s continued role in local NHS healthcare provision is the high standard of care provided.
This is the fourth Quality Account to be submitted by Fulwood Hall Hospital and has been produced to demonstrate our commitment to measuring all feedback from patients about their experience, clinical treatment and clinical outcomes. This allows us to continually review, reflect on and improve the patient’s journey.
Patient safety is our highest priority and our robust recruitment processes and training programmes ensure that staff are competent and fully trained in all aspects of service provision.
We achieve consistently high patient satisfaction scores and, by studying results throughout the year, we constantly seek ways to further improve the patient experience.
Whilst patient feedback and involvement is extremely important to us, we also rely heavily on other measures of safety and clinical effectiveness which we use to satisfy ourselves that treatment is evidence-based and delivered by appropriately qualified and experienced doctors, nurses and other key healthcare professionals. Examples of these are detailed in this Quality Account.
As General Manager of Fulwood Hall Hospital, I am passionate about ensuring that high quality patient care is our number one priority. Our Quality Account is an accurate representation of our performance and our ongoing initiatives to continuously improve the quality of our services.
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To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate .
Debbie Craven, General Manager
Fulwood Hall Hospital, Ramsay Health Care UK
This report has been reviewed and approved by:
NHS Greater Preston Clinical Commissioning Group
Mr Ben Shaw, Consultant Surgeon and Chair Medical Advisory Committee,
Fulwood Hall Hospital
Stefan Andrejczuk, Regional Director, Ramsay Health Care
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Since 1986, Fulwood Hall Hospital has provided independently funded surgical services and diagnostics from its location near the M55 / M6 motorway link in
Preston. Since a £9m refurbishment and expansion in 2009, the hospital has:
 a consultant body of over 150 across a full mix of specialities
 six private consulting rooms
 an outpatient treatment room for minor procedures

three ultra clean, laminar flow theatres
 endoscopy suite
 a close care ward for higher risk patients
 twelve day-case bays for ambulatory care
 22 single-bedded and 3 two-bedded, en-suite bedrooms for overnight stays

a fully equipped physiotherapy gymnasium
 onsite MRI, X-ray and Ultrasound
 a specialist ophthalmology suite
The hospital has had a continuous relationship with local Trusts and Commissioners to support NHS capacity issues and now provides NHS patients with a range of
Choose and Book services in order to support the achievement of 18 week referral to treatment timescales. NHS surgical services provided at the hospital in the year
2013/14 were Ear Nose and Throat, General Surgery, Gynaecology, Ophthalmology,
Oral Surgery, Orthopaedics, Spinal Surgery and Urology.
The hospital also treats patients from 3 years of age and provides specialist paediatric nurses to ensure children (and their parents) receive full reassurance and support throughout their stay.
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On an annual cycle, Fulwood 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 ongoing at any one time. The priorities are determined by the hospital
’s Senior Management Team taking into account patient feedback, audit results, national guidance and the recommendations from various hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.
2.1.1 A review of clinical priorities 2013/14 (looking back)
Surgical Safety Checklist - There have been no ‘Never Events’ at Fulwood 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
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demonstrate that compliance remains high, achieving between 97% and 100% in the period.
PLACE (Patient-led assessment of the care environment) – The first PLACE assessment was carried out in the year, with patient representatives performing the assessment with members of Fulwood Hall Hospital management, scoring an average of 96% for the four areas of cleanliness, food, privacy and the condition of facility.
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. There have been no serious untoward incidents reported in the period.
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.
Meeting Endoscopy Standards – Fulwood Hall Hospital was successful in achieving JAG accreditation in December 2013 following a comprehensive assessment. This is a huge achievement for the hospital endorsing the excellent endoscopy service provided to the local community.
Patient Satisfaction Survey – The hospital’s web-based satisfaction survey has been in place since February 2013 and response rates have gradually increased over the period with a response rate of 51.4% at the end of March 2014. The overall satisfaction rate for the year was 96%. We have gained a five 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 – Fulwood Hall Hospital has achieved the information security accreditation ISO 27001. The process of raising the importance of data protection
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and information security has been successful and has been fully embraced by our staff.
Clinical Documentation Audits Remain a priority in all areas with a national
Ramsay focus set for 2014/15 on theatre safety checks and physiotherapy documentation checks.
Local CQUINS
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.
National CQUINS
Friends and Family Test – The hospital undertook Friends & Family testing with both inpatient and daycase patients in the period, achieving a 50% response rate and a 99% rate for ‘Extremely Likely to recommend’. The hospital undertook
Friends & Family testing with staff in the period, achieving a 68% response rate and a 97% rate for ‘Extremely 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 this reaching 100% compliance in April 2014.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient Safety
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
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regular audit and reviewed by the hospital’s Clinical Governance and Medical
Advisory Committees.
NHS Safety Thermometer - The NHS Safety Thermometer is a national CQUIN to measure, monitor and analyse patient harms and ensure 'harm free' care. Fulwood
Hall Hospital has been 100% compliant with data submission and will continue to submit this data in relation to pressure ulcers, falls and urinary tract infection in those with a catheter.
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 Fulwood 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. Acknowledging the Cavendish review we are adopting the ‘productive team’ model ensuring ‘a holistic approach to care, focused on ensuring the best possible outcomes for the patient, staff and the organis ation’. We promote a culture of support and mentoring in developing our existing staff and we will be introducing apprenticeships across different job roles in the next year.
Clinical Effectiveness
Maintaining Endoscopy Standards
– Following successful JAG (Joint Advisory
Group on Gastrointestinal Endoscopy) accreditation in 2013, biannual submission to
GRS (Global Rating Score) continues, this tool enables us to assess how well we provide a patient-centred service. Demonstrating compliance against the four domains:
clinical quality
quality of patient experience
workforce
training
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Patient Experience
– informing patient choice
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 Clinical Lead 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 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 commited to retaining our five star recommendation. We have added to current patient feedback mechanisms by introducing a patient focus group and including patients in hospital PLACE audits.
Friends and Family Test - The friends and family test has been extended to include outpatients from April 2014. Patients will be invited to complete a paper questionnaire following their visit to the hospital. 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, Fulwood is aiming to achieve 40% in 2014/15.
Patient Reported Outcome Measures Studies (PROMS) –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.
The consultant surgeons will ensure patients are fully informed and invited to take part in the survey by completing a questionnaire prior to their surgery.
Advancing Quality – this initiative is aimed at improving the quality of care and patient experience. It is a local CQUIN where Fulwood Hall Hospital submits data regarding DVT and antibiotic prophylaxis. Compliance with completion of data is expected at 95% and at 80% completion via external audit.
Equality Delivery System – Fulwood 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.
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The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by NHS England.
2.2.1 Review of Services
During 2013/14 Fulwood Hall Hospital provided eight NHS services.
Fulwood 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 1 st
April 2013 to 31 st
March
2014 represents 100% per cent of the total income generated from the provision of
NHS services by Fulwood Hall Hospital for 1 st
April 2013 to 31 st
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 hospital ’s senior managers together with Regional and Corporate Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient safety and quality were:
Human Resources
Staff Cost % 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
Formal Complaints per 1000
HPD's
Patient Satisfaction Score
Significant Clinical Events per
1000 Admissions
Readmission per 1000
Admissions
Quality
Workplace Health & Safety
Score
Infection Control Audit Score
Consultant Satisfaction Score
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2.2.2 Participation in clinical audit
During 1 st
April 2013 to 31 st
March 2014, Fulwood Hall Hospital participated in three national clinical audits.
The national clinical audits that Fulwood Hall Hospital participated in, and for which data collection was completed during 1st April 2013 to 31 st
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
% cases submitted
100%
National Joint Registry (NJR)
63%
Elective surgery (National PROMs Programme)
Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death
0% - no deaths in period
The reports of these national clinical audits were reviewed by the h ospital’s Clinical
Governance Committee.
Local Audits
The reports of local clinical audits from 1 st
April 2013 to 31 st
March 2014 (schedule attached in Appendix 2) were also reviewed by the hospital’s Clinical Governance
Committee.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 to participate in research.
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2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework
A proportion of Fulwood Hall Hospital’s income from 1 April 2013 to 31 st
March 2014 was conditional on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework.
2.2.5 Statements From The Care Quality Commission (CQC)
Fulwood Hall Hospital is required to register with the Care Quality Commission and its current registration status on 31 st
March 2014 is registered without conditions.
The hospital has not participated in any special reviews or investigations by the CQC during the reporting period.
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2.2.6 Data Quality
The hospital continues to take the following actions to improve data quality:
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
Fulwood Hall 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:
T he 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).
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 ’s Information Governance Assessment Report scored 83% overall for 2013/14 and was graded ‘green’ (satisfactory).
Clinical Coding Error Rate
Fulwood Hall Hospital was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission.
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2.2.7 Stakeholders
’ Views on Fulwood
NHS Chorley and South Ribble Clinical Commissioning Group
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Healthwatch
Healthwatch Lancashire were delighted to be able to provide Patient Assessors to Ramsay
Fulwood Hall for its PLACE assessment. Patient Assessor, Jacqui Vella said of her experience during the PLACE assessment at Fulwood Hall Hospital:
“A friendly and welcoming hospital. Even as a smaller hospital, the assessment was very thorough. Our team was myself, two other patients and three members of staff; the assessment saw that inside and outside, the premises were very well maintained. The bedrooms were mainly single rooms, with accommodation to a high standard. The tasting of the NHS menu was lovely – I was tempted to take the chef home with me! Thank you to Healthwatch Lancashire and Ramsay
Health Care – it was a pleasure being part of the volunteer group of assessors.”
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Ann Cooke, Matron Fulwood Hall Hospital
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 op timum 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 develops ways of working which assure that the quality of patient care is central to the organisation.
The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care. Clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All management systems, clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others.
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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
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National Guidance
Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Health and Clinical Excellence (NICE) and Safety
Alerts as issued by the NHS Commissioning Board Special Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that are applicable to our business and thereafter monitoring their implementation.
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National Mortality Rates
Period
2012/13
2013/14
RKE
RKE
Best
0.65
0.63
Fulwood Mortality Rates
Period
2012/13
2013/14
Fulwood
NVC07 0.01
NVC07 0
National Expected Deaths
Period
Apr12 - Mar13
Jul12 - Jun13
RBA
RBA
Best
0.1
0.0
Fulwood Expected Deaths
Period
2012/13
2013/14
Fulwood
NVC07 0.0
NVC07 0.0
RXL
RBT
Worst
1.17
1.15
RWH
RWH
Worst
44.0
44.1
Average
Eng
Eng
1
1
Eng
Eng
Average
20.4
20.2
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PROMs
Fulwood Hall Hospital has taken action to improve the returns rate of PROMs questionnaires and subsequently the quality of its services, by actively involving consultants in the PROMs process to encourage patient participation.
National PROMs (Hernia)
Worst
NVC27 0.015
RNA 0.019
Eng
Eng
Average
0.085
0.086
Period
Apr12 - Mar13
Apr13 - Sep13
NT415
RTG
Best
0.157
0.138
Fulwood PROMs (Hernia)
Period
Apr12 - Mar13
Apr13 - Sep13
Fulwood
NVC07 0.058
NVC07 *
National PROMs (Veins)
Period
Apr12 - Mar13
Apr13 - Sep13
RV8
RTD
Best
5.14
-9.74
Fulwood PROMs (Veins)
Period
Apr12 - Mar13
Apr13 - Sep13
National PROMs (Hips)
Fulwood
NVC07
NVC07
Period
Apr12 - Mar13
Apr13 - Sep13
NT209
NT318
Best
24.68
25.44
*
*
NT350
Worst
-15.92
RLN -10.52
RKE
RHQ
Worst
17.21
18.34
Eng
Eng
Average
-8.374
-9.46
Eng
Eng
Average
21.32
21.61
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Fulwood PROMs (Hips)
Period
Apr12 - Mar13
Apr13 - Sep13
NVC07
Fulwood
22.582
NVC07 *
National PROMs (Knees)
Period
Apr12 - Mar13
Apr13 - Sep13
NT219
Best
RDE
20.37
20.09
Fulwood PROMs (Knees)
Period
Apr12 - Mar13
Apr13 - Sep13
NVC07
Fulwood
17.304
NVC07 *
National Readmissions
Period
2010/11
2011/12
RF4
Best
0.0
RF4 0.0
Fulwood Readmissions
RAP
RM1
Worst
12.46
14.32
RYR
Worst
15.8 Eng
Average
11.04
RYR 15.8 Eng 11.08
Period
2012/13
2013/14
Fulwood
NVC07 6.97
NVC07 6.06
Eng
Eng
Average
16.01
16.74
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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%
Fulwood VTE Assessment
Period
13/14 Q3
13/14 Q4
Fulwood
NVC07 99.7%
NVC07 99.3%
National C-Difficile Rate
Period
2012/13
2013/14
Best
Several
Several
Fulwood C-Difficile Rate
Worst
0 RNA
Average
58.2 Eng 22.2
0 RVW 30.8 Eng 17.3
Period
2012/13
2013/14
Fulwood
NVC07
NVC07
0.0
0.0
National Patient Safety Incident Rate
Period
2011/12
2012/13
RP6
Best
2.6
RRF 2.0
TAJ
Worst
84.4
RAT 85.6
Fulwood Patient Safety Incident Rate
Period
2012/13
2013/14
Fulwood
NVC07 6.1
NVC07 3.6
Average
Eng 13.5
Eng 14.8
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National SUI’s (Severity Level 1)
Period
Jul - Sep 12
Oct11 - Sep12
Best
NA
NA
Fulwood SUI’s (Severity Level 1)
Period
2012/13
2013/14
Fulwood
NVC07 2.4%
NVC07 1.3%
National Friends and Family Test
Worst
NA
NA
Period
Jan-14
Feb-14
Best Worst
Several 100 RPA02 27
Several 100 RPA02 18
Fulwood Friends and Family Test
Period
2012/13
2013/14
Fulwood
NVC07 100
NVC07 93
* Volumes were too low to be reported.
NA
Average
Eng 11,563
Average
Eng 73
Eng 73
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3.2 Patient Safety
We are a progressive hospital and focussed on stretching our performance every year, 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.
3.2.1 Infection Prevention And Control
Fulwood Hall Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 5 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.
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 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.
The consultant microbiologist presented a teaching session to the clinical staff entitled
‘Myth busting’ covering universal precaution guidance in clinical practice which was very well received.
Hand hygiene awareness days are led by the infection control link nurse involving staff, patients and visitors and information in waiting areas.
Observational hand hygiene audits were undertaken by the Consultant Microbiologist and Infection Control Link Nurse resulting in additional gel dispensers being placed in the unit.
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Our infection control rate remains very low and our reporting and investigating of potential infections has improved in the last year. Any patient presenting signs of an infection is reviewed by the infection control link nurse and a root cause analysis completed 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.
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2011/12 2012/13
Fulwood Hall Hospital
2013/14
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 Fulwood Hall Hospital, providing us with a patient’s eye view of the buildings and facilities, giving us a clear picture of how the people who use our hospital see it and how it can be improved. The Hospital scored
96% for the four areas of cleanliness, food, privacy and the condition of facility during the period. An action plan was compiled and managed by senior management to ensure feedback was acted upon and facilities remain of a high standard.
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3.2.3 Safety In The Workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety.
Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay
Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues.
In addition to mandatory training the Health and Safety Coordinator has coordinated sharps awareness programmes throughout the year ensuring the use of sharps safe devices where these are available. There has also been training on waste management ensuring the correct segregation of waste taking into account the effect on the environment and raising staff awareness on this issue.
3.3 Clinical effectiveness
Fulwood Hall hospital has a Clinical Governance committee that meet regularly through the year to monitor quality and effectiveness of care. Clinical incidents together with patient and staff feedback are systematically reviewed to determine any trends that require further analysis or investigation. More importantly, recommendations for action and improvement are presented to hospital management and the hospital’s Medical Advisory Committee to ensure results are visible and tied into actions required by the organisation as a whole.
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.
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0.6
0.5
0.4
0.3
0.2
0.1
0
2011/12 2012/13
Fulwood Hall Hospital
2013/14
Fulwood Hall Hospital continues to have a very low return to theatre rate as a percentage of overall admissions. There were no trends identified and the increase seen from 2012/13 is still below the national average.
3.4 Patient Experience
All feedback from patients regarding their experiences with Ramsay Health Care is 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 fed back to the relevant staff directly. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.
Patients ’ experiences are fed back via the various methods below, and are standard agenda items on local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and NHS England bodies occurs as required and according to NHS policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Via a web based survey invitation
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‘Hot alerts’ are received within 48hrs of a patient making a comment on the web survey
Friends and family questions asked on patient discharge
The hospital’s ‘We value your opinion’ leaflet which is given to all admitted patients
Verbal feedback from patients to hospital staff - including Consultants, Matron, and General Manager whilst visiting patients and also during CQC visit feedback
Written feedback via letters and emails from patients
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 patients ’ 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 a re 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. Please note, a change of satisfaction survey in early 2013 means the year on year data shown in the column graph is not comparable, however we continue to achieve a satisfaction score for more than 9 out of 10 patients.
NHS/Private Patients
150
100
50
0
98.2 94.0
2012/13
Fulwood Hall Hospital
2013/14
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During 2013 Fulwood Hall Hospital worked towards achieving JAG accreditation. As part of this project the hospital was keen to involve patients in ensuring the service was designed to meet their needs. An anonymous patient questionnaire was produced and given to all Endoscopy users during the period running up to accreditation. The findings of which were reviewed by an Endoscopy service Group including representation from Consultant Gastroenterologists, Endoscopy Lead, Matron, administration and clinical staff.
To ensure patients were represented in the user group the Endoscopy Lead and the rest of the endoscopy team actively sought patient feedback via direct discussions with patient and via the formal questionnaire survey.
Two areas were debated: offering a choice of morning or afternoon appointments had been raised in the survey results and the user group committed to review schedules and gastroenterologist availability to ensure choice across the week was offered.
Secondly the availability of a private room for patients to have their care discussed with the gastroenterologist was discussed. Whilst the patient representative felt that the individual pods pre and post procedure afforded sufficient privacy a dedicated discharge room was subsequently created as well as access to a private room for the breaking of bad news.
The endoscopy team found the contribution of patient feedback invaluable and in working towards successfully achieving Jag accreditation patient feedback played a key part in the preparation. The Jag assessors commended the endoscopy team on their preparation and excellent endoscopy service provided; they were particularly impressed with the team for inviting patients in the service design.
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(Received via Friends & Family May 2014)
“I have just returned home for FHH after a knee replacement. I would like to congratulate the hospital on its excellence of service and care and the kindness shown to me from the Consultant, Mr (****), the anaesthetist Mr (****) and the operating room.”
“Everything that was needed was done well.”
“Staff very caring and explained clearly what to expect. Rated excellent in care, cleanliness, staff, accommodation, I was well looked after thank you.”
“Staff were caring and compassionate, no problems, thank you. I was thoroughly satisfied with my stay and the care and staff are wonderful thank you.”
“Everything was done well. The care I had could not have been improved on, all the staff work incredibly hard to make you welcome and comfortable, thank you.”
“Staff attention to detail was done well, The staff at Fulwood Hall are a credit to the profession, my best hospital experience to date, V Impressed!”
“Excellent staff, I felt well looked after!”
“Very attentive and reassuring staff, theatre staff excellent, very professional and caring.”
“You all made me at ease and very helpful, thank you very much for everything you did for me. Care was excellent.”
“From being admitted to leaving, the service has been excellent. So much kindness and care shown, congratulations to your hospital for its excellent service.”
“Everything was done well. Friendly welcoming environment. Clean & Comfortable rooms. The staff were caring and friendly.”
“Care was fantastic, special mention to the nurse (******) who was very helpful and explained everything to me. An excellent hospital, very clean and helpful, friendly staff.”
“Everything from reception to day and night staff, very helpful and caring, would come here every time if I could.”
“Please pass on my very grateful thanks to Mr (*****) for my recent hip op. I was treated by all the staff at FHH in a very kind professional manner. It really does make all the difference when you are having surgery.”
“You did well at everything, cannot rate you high enough. Your nursing staff are wonderful and reception are very kind also, your catering staff are very helpful.”
“Everyone was very pleasant, well informed about what was happening.”
“Excellent nursing care, I wish all of the NHS were as efficient as Ramsay.”
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Appendix 1
Services Provided Peoples Needs Met for:
Treatment of
Disease,
Disorder
Or injury
Cosmetics, Dermatology,
Ear, Nose and Throat (ENT),
General surgery,
Gynaecological, Ophthalmic,
Orthopaedic, Physiotherapy,
Rheumatology, Sports medicine, Urology, Spinal,
Pain Management
All adults 18 yrs and over
Children 3 years and above
Surgical
Procedures
Diagnostic and
Screening
All adults 18 yrs and over excluding:
Breast surgery, Cosmetics,
Day and Inpatient Surgery,
Dermatology, Ear, Nose and
Throat (ENT), General surgery, Gynaecological,
Ophthalmic, Oral maxillofacial surgery,
Orthopaedic, Urology,
Spinal
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.
Children 3 years and above
Imaging services,
Phlebotomy, Urinary
Screening and Specimen collection.
All adults 18 yrs and over
Children 3 years and above
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Appendix 2 – Clinical Audit Programme 2013/14.
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