New Hall Hospital
Quality Account
2013/14
No reported MRSA bloodstream infections
In the past 5 years
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 2013/14 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
New 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 and Clinical
Commissioning Groups.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring
that high quality patient care is our number one goal. This relies not only on
excellent medical and clinical leadership in our hospitals but also upon an
organisation wide commitment to drive year on year improvement in patient
satisfaction and clinical outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is not
about reliance on one person or a small group of people to be responsible and
accountable for our performance. It is essential that we establish an
organisational culture that puts the patient at the centre of everything we do and
as a long standing and major provider of healthcare services across the world,
Ramsay has a very strong track record as a safe and responsible healthcare
provider and we are proud to share our results.
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every year
we set our targets higher, working on every aspect of our service to bring a
continuing stream of improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
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Introduction to our Quality Account
This Quality Account is New Hall Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Welcome to New Hall Hospital’s quality account. This report outlines the
Hospitals approach to quality improvement, progress made in 2013-14
and plans for the forthcoming year.
New Hall Hospital has five key values which underpin everything we do as
an organisation:
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Put the patient first
Work as one team
Respect each other
Strive for continual improvement
Respect environmental sustainability
The aim of our Quality Account is to provide information to our patients
and commissioners to assure them we are committed to making
progressive achievements. For example, we participate in the Health
Protection agency’s Surgical Site Surveillance Service and Patient
Reported Outcome Measures for Hip and Knee replacement, hernias and
cataracts.
Our emphasis is on ensuring patients receive safe, efficient and effective
care, that they feel valued, respected and involved in decisions about their
care and are fully informed about their treatment each step of the pathway.
The experience that patients have in our hospital is of the utmost
importance and we are committed to establishing an organisational culture
that puts the patient at the centre of everything we do. As well as being
treated quickly and safely, our patients receive a personalised service,
enhanced by good communication and a commitment to ensuring their
privacy and dignity are respected at all times.
High quality patient care is at the centre of what we do and how we
operate our hospital. To do this we rely on excellent medical and clinical
leadership plus an overall continuing commitment to drive year on year
improvement in clinical outcomes.
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We especially value patient’s feedback about their stay, treatment and
clinical outcome. In the last year we have taken part in the QE research
Inpatient survey and received excellent feedback. We have also
participated in the patient and staff NHS Friends and Family Survey, and
have been delighted with the many positive comments we have received.
In 2013-2014 we underwent significant refurbishment of all en suite
rooms, reception and premium care lounge. We also developed and
implemented the Surgical Admissions unit to further improve the quality
of service we offer.
Fiona Taylor
General Manager
New Hall Hospital
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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.
Fiona Taylor
General Manager
New Hall Hospital
Ramsay Health Care UK
This report has been reviewed by:
MAC Chair-Mr David Chapple
Clinical Governance Committee Chair-Mr Peter Guy
Regional Director Stefan Andrejczuk
Commissioner/PCT and other external bodies
Wiltshire CCG
Dorset CCG-Sally Shead Director of Quality
Hampshire CCG-Andrea O Connell Director of Quality
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Welcome to New Hall Hospital
New Hall Hospital
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New Hall Hospital is an independent hospital delivering a full range of
specialist surgical and medical services. The hospital is set in beautiful
grounds and the original Georgian manor House now accommodates three
theatres and 43 beds with excellent physiotherapy and radiology services.
Consideration for our patients is at the heart of everything that we do. We
are constantly seeking new ways of working and bringing in fresh clinical
practices that will improve outcomes for our patients. Our approach to
service delivery, which includes working in partnership with the NHS, is
courteous and professional and we take great pride in our ability to
innovate and look at new ways of working.
We provide fast, convenient, effective and high quality treatment for
patients of all ages (excluding children below the age of 18 years or 16 if
private), whether medically insured, self-pay, or from the NHS).
We deliver a full range of specialist surgical and medical services
(excluding cardiac and neurosurgery) to include orthopaedics, spinal, ENT,
gynaecology, urology, colorectal, breast and cosmetic surgery and general
medicine.
Patients requiring level 2 critical care are treated and cared for by
appropriately trained staff in a dedicated high dependency unit.
All Ramsay Health Care UK hospitals have transfer arrangements in place
with their local trust or critical care network for level 3 care.
In 2013/14 we treated a total of 5856 patients. 4131 NHS patients (70%)
and 1725 private patients (30%).
We currently employ
Consultants (directly employed by Ramsay)
3
Consultants (with practicing privileges)
100 (all specialities)
Registered Nurses
40 + 8 bank
Operating Department Practitioners
10 + 3 bank
Radiographers
4 + 5 bank
Physiotherapists
5 + 4 bank
Health Care Assistants
19
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Other Support Staff
21 + 4 bank
Administrative staff
46 + 8 bank
The staff to patient ratio is 1:between 5 and 8 (depending on patient
dependence and there is an experienced Residential Medical Officer
(RMO) on site 24 hours a day
We provide an outreach service for outpatient NHS patients at Poole
Hospitals and Blandford clinic for spinal and orthopaedic services.
We offer direct referral services for private Cosmetic Surgery and
aesthetic cosmetic treatments. All patients requiring NHS services are
referred via their General Practitioner (GP)
We have a dedicated GP liaison officer who has close contact with both
the practice managers and the GPs at practices throughout Wiltshire,
Hampshire and Dorset. She visits GP practices and organises regular
“Lunch and Learns” and breakfast meetings taking Consultants into GP
surgeries to offer training. In addition she also runs regular Consultant led
open evenings for GP’s.
We work closely with our local Clinical Commissioning Groups (Wiltshire,
Hampshire, Dorset and Somerset) to provide a range of surgical services
within the standard acute contract.
We work closely with the Salisbury District Hospital who provide us with
blood transfusion, urgent pathology, histopathology and access to level 3
critical care services.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle New Hall 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)
1. World Health Organisation (WHO) Surgical safety checklist –
completion of the checklist is a key safety element for patients undergoing
surgical procedures at New Hall. Accurate completion of the WHO
checklist is audited regularly and the results are consistently over 90%
compliance.
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2. Bar coding for patient identity bands – this priority has been on hold
awaiting a formal notice for implementation. However, this is still on
Ramsay’s agenda and will be introduced as it is still considered best
practice and will prepare us for many patient care initiatives which will
require patients to have a barcode on their wristbands.
3. Venous Thromboembolism (VTE) risk assessment and Prevention
New Hall hospital has established a robust policy to comply with Ramsay
policy in order to reduce avoidable death, disability and chronic ill health
from VTE. We have reduced the variance of prophylactic measures used
at New Hall hospital in order to minimise human error and allow outcomes
to be measured. The hospital has an excellent VTE risk assessment
compliance record. Data submitted to UNIFY shows 99.8% achievement
from April 13th to March 14.
4. Never Events’ are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been
implemented.
Preventative measures have been implemented and there have not been
any “Never event” incidents in this reporting year at New Hall hospital
5. Real time incident reporting – All incidents, complaints and clinical key
performance indicators such as readmissions, reoperations, healthcare
acquired infections etc. are entered onto the corporate risk management
system (RISKMAN) in real time so trends can be analysed and identified
promptly. This enables us to review events as they happen and prevent
recurrence thus contributing to patient safety.
6. JAG Accreditation-We were delighted to pass our JAG accreditation
assessment first time on 3rd July 2014. This will allow us to further enhance
our endoscopy service and provide reassurance to commissioning bodies
that we meet all the criteria to run a safe, efficient and effective service.
7. Cleanliness and infection prevention - There have been no MRSA
bacteraemias or C Difficle at the hospital over this reporting period. We
screen all patients for MRSA prior to admission to New Hall and all staff
have a mandatory requirement to undertake hand hygiene training. We
maintain our regular audit programme which includes hand hygiene, urinary
catheter and intravenous line care, and our cleaning standards and
physical environment. We participate in the Health Protection Agency data
collection for surgical site infections following hip and knee joint
replacements and we have not had cause to report any infections to the
HPA during the last year.
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8. National Joint Registry (NJR) The purpose of the NJR is to define,
improve and maintain a quality of care of individuals receiving hip, knee and
ankle joint replacements across the NHS and independent healthcare
sector. Shoulder and elbow replacements have also been added to the list
in addition to those above. New Hall registers all patients undergoing this
type of surgery with the NJR providing they consent to this. The NHS
number tracing rate is to ensure that patients can be traced easily and
information from different providers can be collated. All staff that input the
data have been informed how to ensure NHS number tracing can be
achieved to achieve a 100% traceability rate. We have maintained
consistently good scores for data submission to the NJR.
9. Clinical training – New Hall hospital will continue to ensure that patients
are cared for by safe and competent staff. Providing quality care for
patients is a high priority at New Hall Hospital and all relevant clinical staff
will be supported through training and protected time to achieve
competency level education. Blood transfusion competencies – in line with
patient safety we will ensure that blood transfusions or blood products are
only handled/administered by competent trained staff. New Hall hospital
has achieved good levels of compliance with mandatory training/e-learning.
10. Safeguarding- New Hall hospital takes its responsibility for safeguarding
vulnerable members of society seriously. We provide in house training and
easy to use flowcharts for help and advice. These are available in all areas.
All staff working within the hospital are required to have an enhanced CRB
check and have undergone mandatory training in safeguarding. Relevant
staffs have also undergone training in the Mental Capacity Act and
Deprivation of Liberty although neither have had to be used in this reporting
period. The PREVENT programme to identify and support vulnerable
individuals who may be at risk of radicalisation is mandatory and is
currently underway for all members of staff to attend. Equality, diversity and
human rights are a theme running through Ramsay Health Care. The
organisations integrated governance framework, Group policies and
practice comply with current legislation. To date there have not been any
safeguarding incidents to report at New Hall Hospital.
11. Information Security-New Hall Hospital was re audited in March 2013 and
achieved Information Security accreditation ISO270001.
12. Staffing- Ramsay invested in an electronic rostering system in 2013
(Allocate) Departmental Managers are required to put key staffing
requirements into the system which then generates an auto roster in line
with staffing key performance indicators and local staffing requirements.
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This has the added advantage of recording training hours and reminds staff
of key training requirements and professional registrations.
Clinical effectiveness
Surgical Admissions Unit – better outcomes and improving patient experience
In December 2013 we opened our Surgical Admissions Unit. This was in order to
provide our patients with a more efficient patient pathway through the hospital. All
patients are admitted via the Surgical Admissions unit which is adjacent to
theatre. This close proximity to theatre has allowed us to implement staggered
admissions so patients aren’t waiting for significant amounts of time pre
operatively. Patients who are undergoing day case procedures appreciate the
efficient of the system which means they only have to spend a short period of
time in hospital. We are the first hospital within the Ramsay group to develop a
Surgical Admissions unit and proud that it has provided a much more efficient t
service for our patients
Electronic patient information
All patients are sent a substantial amount of paperwork prior to admission and
concerns were raised that information was getting lost and not received. We
implemented the process of putting all the patient information on line and setting
up a secure email by which the patient could receive all communication. This is
not only easier for the patient but also ensures an audit trail as to when and
where documents were sent.
Group pre assessment
New Hall pre-assessment and physiotherapy team have implemented a group
pre assessment process for all spinal surgery. It was recognised that seeing each
patient individually was not always the most efficient way of giving the required
pre-operative information to patients and that holding group sessions encouraged
discussion and group interaction. The patients are first assessed at time of
consultation to ensure they are fit for surgery and then they are invited to attend a
group session where they are given a procedure specific presentation by the
physiotherapist and/or spinal nurse practitioner and an opportunity to ask
questions and meet other patients having the same procedure. The group
session is followed up by an individual assessment by the spinal nurse
practitioner.
Private Hospitals Information Network
Ramsay Health Care is a member of Private Hospitals Information Network which
enables providers to benchmark against other providers for key performance
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indicators (activity volumes, mortality, day case rates, return to theatre,
readmissions etc.
Improve National benchmarking
it was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve our
services. This is even more important now we are working in partnership with the
NHS. We will be benchmarking in the following areas;
VTE risk assessment compliance – benchmarking through the national stats
website. Link;
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publication
sStatistics/DH122283
PROMS results – benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categ
oryID-1295
Patient experience – informing patient choice
Patient Reported Outcomes Studies (PROMs)- We continue to monitor the
national PROMs results for Hip, Knee, Varicose Veins and Hernia surgery by
offering all patients who undergo this type of surgery the opportunity to complete
a questionnaire before and after surgery to monitor an improvement in their
quality of life. Encouraging their use in identifies poor outcomes and allows us to
review practice where necessary.
We share the results with Surgeons and physiotherapists and encourage them to
use them to review their practice by meeting and discussing the results with their
teams and benchmarking against other sites.
We are expanding our use of PROMS surveys to cover more procedures to
enable better understanding of treatment outcomes from the patients view point.
We have also implemented PROMS for spinal surgery using the British Spinal
Registry.
Patient satisfaction survey – New Hall has always achieved a high level of
patient satisfaction even during the recent refurbishment. During 2013 the paper
based survey was replaced by a web based questionnaire/telephone survey
which allows feedback to be received more quickly. We receive a weekly “hot
alert” comments so we can respond to concerns in a more timely manner.
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The latest formal report relates to patients discharged in July 2014 and there was
a response rate of 60%. In response to the question, Overall, how would you rate
your experience, New Hall scored 97% and 97% of patients said they would
recommend the hospital. All patients are given a “we value your opinion” leaflet
on discharge and asked to take the friends and family test which is where they
say whether they would recommend the hospital to their friends and family. The
friends and family test has also recently been rolled out to outpatients.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient Safety
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We will increase the number of patients who report they attend primary or
secondary care on discharge in relation to their primary procedure at New
Hall Hospital. We will monitor this by phoning patients 30 days post
discharge. This is a local CQUIN agreed with Wiltshire CCG and will
ensure that patients are being discharged appropriately and with
comprehensive follow up advice.
Clinical Effectiveness
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To reduce the number of avoidable admissions within 30 days of surgery.
This will be monitored via NHS clinical indicators which includes
readmission to other hospitals.
Patient Experience
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Increase the number of patients who receive copies of their Consultant to
GP letter. This is so patients can be kept fully informed regarding their care
and discharge. This will be monitored via the patient questionnaire.
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We will continue to improve the services offered to patients to ensure they
receive a positive experience. This will be monitored via the patient
questionnaire and the friends and family test and “we value your opinion”
leaflet.
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2013/14 New Hall Hospital provided and/or subcontracted 7 NHS
specialties through the choose and book system.
New 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 April 2013 to 31st
March 14 represents 76.64 % of the total income generated from the provision of
services by New Hall Hospital 1 April 2013 to 31st March 14
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospitals
senior managers together with Regional and Corporate Senior Managers and
Directors. The balanced scorecard approach has been an extremely successful
tool in helping us benchmark against other hospitals and identifying key areas for
improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
Staff Cost as % Net Revenue
HCA Hours as % of Total Nursing
Agency Cost as % of Total Clinical Staff Cost
Ward Hours PPD
% Staff Turnover rolling 12 months
% Sickness rolling 12 months
% Lost Time
Appraisal %
Staff Satisfaction Score (max possible 7)
28.7%
22%
1.4%
4.3
11.1
4.43
18.9%
100%
4.89
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Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
0
Workplace Health & Safety Score
Infection Control Audit Score
99%
88%
0.2%
96%
2.2
5.1
2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014 New Hall Hospital participated in 100%
national clinical audits it was eligible to participate in. The Hospital was not
eligible to participate in any of the National Confidential Enquiries
The national clinical audits and national confidential enquiries that New 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
83%
72%
The reports of two national clinical audits from 1 April 2013 to 31st March 11 2014
were reviewed by the Clinical Governance Committee and New Hall Hospital
intends to take the following actions to improve the quality of healthcare provided
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Continue to improve our systems for submitting data
Continue to ensure all patients are encouraged to complete the PROMS
questionnaires and the reasoning behind this.
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Local Audits
The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and New Hall Hospital intends to
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take the following actions to improve the quality of healthcare provided. The
clinical audit schedule can be found in Appendix 2.
The audit results at New Hall show a consistently good level of completion with
appropriate action plans and outcomes. We will continue to further improve our
standards of record keeping and infection control practices.
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 New Hall Hospital income in from 1 April 2013 to 31st March
2014 was conditional on achieving quality improvement and innovation goals
agreed with Wiltshire CCG, Dorset CCG and Hampshire CCG and any person or
body they entered into a contract, agreement or arrangement with for the
provision of NHS services, through the Commissioning for Quality and Innovation
payment framework.
Agreed goals for 14/15
Dorset CQUINS
National CQUINS
1a-F&F-implementation of staff F &FT
1b-F&F Early implementation of F&F in OPD/Physio/Radiology
2-F&F-Increased or maintained response rate
3-F&F-Decreasing –ive responses
2.1a-NHS safety thermometer-Reduction in Stage 2 pressure ulcers
2.1b- NHS safety thermometer-Prevalence of pressure ulcers
2.1c-Inherited pressure ulcers
2.1d-Participation in pressure ulcer working group
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Local CQUINS
Catheter care bundle-urinary catheters-monthly audit 10 sets of notes
Establishing mental capacity at pre assessment-All patients >65 years
Peripheral vascular access device-monthly audit 10 sets of notes
Cauda equina monitoring-no of referrals, route of referrals and outcomes
Hampshire CQUINS
National CQUINS
1b-F&F Early implementation of F&F in OPD/Physio/Radiology
2-F&F-Increased or maintained response rate
2.1b- NHS safety thermometer-Reduction in Prevalence of pressure ulcers
Local CQUINS
Improving patient experience-Work with group of patients to identify areas for
improvement-equality questionnaire
Outpatient follow up reform-review face to face follow up except where there is a
clear clinical rationale
Wiltshire CQUINS
1a-F&F-implementation of staff F &FT
1b-F&F Early implementation of F&F in OPD/Physio/Radiology
2-F&F-Increased or maintained response rate
3-F&F-Decreasing –ive responses
2.1a-NHS safety thermometer-Reduction in Stage 2 pressure ulcers
2.1b- NHS safety thermometer-Prevalence of pressure ulcers
2.1c-Inherited pressure ulcers
2.1d-Participation in pressure ulcer working group
Local CQUINS
Continuity of care
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Reducing face to face follow up
2.2.5 Statements from the Care Quality Commission (CQC)
New Hall Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions.
The Care Quality Commission has not taken enforcement action against New Hall
Hospital during 2013/14
New Hall 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
We regularly use statistical data to monitor clinical services-we are constantly
reviewing this information by quality control initiatives.
Medical records are audited monthly and action plans developed in response to
concerns as required.
New Hall Hospital has a data quality super user who manages the SUS pathway
and processes to ensure data quality.
NHS Number and General Medical Practice Code Validity
New 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:
The patient’s valid NHS number:
 99.97% for admitted patient care;
 99.96 for out patient care; and
 0% for accident and emergency care (not undertaken at our hospital).
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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).
Clinical coding error rate
New 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 2013/14 Quality Account
West Hampshire CCG are pleased to be able to comment on Ramsay Health Care New Hall
Hospital’s Quality Report for 2013/14. The CCG is satisfied with the overall content.
West Hampshire CCG would like to congratulate New Hall Hospital on the achievement of a
number of quality outcomes detailed in its 2013/14 Quality Report including:
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Excellent record of Venous Thromboembolism (VTE) risk assessment
Zero cases of MRSA bacteraemia and Clostridium difficile
Implementation of a process that enables patients to securely access patient information
about their procedures to reduce the risk of information being mislaid
The positive results from the patient satisfaction surveys are encouraging, with an average of
96% of patients stating they would be likely to recommend New Hall hospital to friends and
family if they needed similar care or treatment during April 2013 – March 2014. It is pleasing to
note that New Hall Hospital have a number of methods for obtaining patient experience
information and for gaining the patient perspective and that they have agreed to undertake the
West Hampshire CCG local Patient Experience Commissioning for Quality and Innovation
(CQUIN) scheme during 2014/15. It is noted that New Hall Hospital are now rolling out the
Friends and Family Test to outpatients.
The CCG notes that the 2013/14 Patient Led Assessments of the Care Environment (PLACE)
results demonstrated that New Hall Hospital was slightly below the National and Ramsay Health
Care average for ‘cleanliness’, ‘privacy, dignity and well-being’ and ‘condition and appearance’.
However the CCG were aware of the refurbishment that was being undertaken at the time and
were assured that the Hospital had actions plans in place to respond to the audit findings. The
2014/15 results demonstrate internal improvement in ‘cleanliness’, ‘condition, appearance and
maintenance’.
The Care Quality Commission carried out one routine unannounced visit to the hospital in
2013/14 (8th January 2014) and all standards reviewed were deemed as met.
Overall, West Hampshire CCG are satisfied with the Quality Report for 2013/14. We look
forward working closely with New Hall Hospital over the coming year and will review
achievement of the 2014/15 quality priorities and indicators through the Clinical Quality Review
Meetings in order to further improve the quality of local health services.
Quality Accounts 2013/14
Page 22 of 43
Yours sincerely
Andrea O’Connell
Director of Quality (Board Nurse)
Dear Fiona
Fiona Taylor
New Hall Hospital
Salisbury SP5 4EY
Quality Account 2013/14
Thank you for asking NHS Dorset Clinical Commissioning Group (CCG) to review and
comment on your Quality Accounts for 2013/14. Please find below the CCG’s statement for
insertion into the Quality Accounts.
Over the past year New Hall has consistently remained focussed on improving the quality of
care provided to individuals who use their services. The key priorities identified for 2013/14
have been successful. With high level of compliance with WHO surgical checklist and the
completion of VTE risk assessment, the hospital has exceeded the expected levels.
The CCG recognises the effort that is put in to development of new ways of working within
the hospital including the revised pre-assessment process and the introduction of surgical
admission unit; both systems designed to improve patient experience.
During the year the Care Quality Commission conducted an inspection visit to the
organisation which found that all areas inspected were compliant. In addition the Hospital
has also achieved JAG and Information Security accreditation.
The CCG has not been actively engaged in the development of the Quality Improvement
Priorities that the Hospital has set for 2014/15 but is in support of these priorities as they
align to reduction of re-attendance following admission to hospital and improve the process
for sharing information with individuals about their care they have had or will be receiving.
Quality Accounts 2013/14
Page 23 of 43
2
Please do not hesitate to contact me if you require any further information.
Yours sincerely
Sally Shead
Director of Quality
Quality Accounts 2013/14
Page 24 of 43
Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Deborah Stott Matron
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our
performance on many levels, we reflect on the valuable feedback we receive from
our patients about the outcomes of their treatment and also reflect on
professional opinion received from our doctors, our clinical staff, regulators and
commissioners. We listen where concerns or suggestions have been raised and,
in this account, we have set out our track record as well as our plan for more
improvements in the coming year. This is a discipline we vigorously support,
always driving this cycle of continuous improvement in our hospitals and
addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe
in being open and honest where outcomes and experience fail to meet patient
expectation so we take action, learn, improve and implement the change and
deliver great care and optimum experience for our patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
Quality Accounts 2013/14
Page 25 of 43
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 26 of 43
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.
Quality Accounts 2013/14
Page 27 of 43
3.1 The Core Quality Account indicators
Mortality
Period
Best
Worst
Average
Period
New Hall
2012/13
RKE
0.65
RXL
1.17
Eng
1
2012/13
NVC09
0.03
2013/14
RKE
0.63
RBT
1.15
Eng
1
2013/14
NVC09
0
New Hall Hospital considers that this data is as described for the following
reasons

There are very few deaths at, or following treatment at this hospital.
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

Maintain a safe and efficient pre assessment service to ensure patients are
optimised prior to surgery. Ensure all staff are appropriately trained and
assessed.
Re-admission
Period
Best
Worst
Average
Period
New Hall
2012/13
RF4
0.0
RYR
15.8
Eng
11.04
2012/13
NVC09
4.7
2013/14
RF4
0.0
RYR
15.8
Eng
11.08
2013/14
NVC09
7.91
New Hall Hospital considers that this data is as described for the following
reasons

New Hall hospital have a significantly high complexity factor and have an
active policy of readmitting patients rather than redirecting them to other
sites
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

Maintain a comprehensive discharge process with appropriate post
discharge information and support.

To continue to monitor admissions to other sites
Quality Accounts 2013/14
Page 28 of 43
PROMS
Hernia
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
Period
Apr12 Mar13
Apr13 Sep13
New Hall
NVC09
NVC09
New Hall Hospital considers that this data is as described for the following
reasons

The number of hernia procedures is too small for New Hall to participate
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

It will ensure all patients undergoing this procedure are offered the
opportunity to undertake this measure and participate if numbers are
sufficient
Veins
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
Period
Apr12 Mar13
Apr13 Sep13
New Hall Hospital considers that this data is as described for the following
reasons

The number of vein procedures is too small for New Hall to participate
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

It will ensure all patients undergoing this procedure are offered the
opportunity to undertake this measure and participate if numbers are
sufficient
Quality Accounts 2013/14
Page 29 of 43
New Hall
NVC09
NVC09
*
Hips
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT209
24.68
RKE
17.21
Eng
21.32
NT318
25.44
RHQ
18.34
Eng
21.61
Period
Apr12 Mar13
Apr13 Sep13
New Hall
NVC09
21.746
NVC09
New Hall Hospital considers that this data is as described for the following
reasons

Patients reporting good outcomes when completing their post op
questionnaire
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

To continue to improve return rates
Knees
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
Period
Apr12 Mar13
Apr13 Sep13
New Hall
NVC09
NVC09
New Hall Hospital considers that this data is as described for the following
reasons

Patients reporting good outcomes when completing their post op
questionnaire
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

To continue to improve return rates
Quality Accounts 2013/14
Page 30 of 43
16.111
Responsiveness to personal care
Period
Best
Worst
Average
Period
New Hall
2012/13
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC09
90.3
2013/14
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC09
90.9
New Hall Hospital considers that this data is as described for the following
reasons


We ensure all staff are aware of the need for excellent customer service
Care planning is individualised and takes into account the holistic needs of
the patient.
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

To ensure patients’ needs are at the forefront of everything we do.
VTE
Period
Best
Worst
Average
Period
New Hall
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q3
NVC09
100.0%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
13/14 Q4
NVC09
100.0%
New Hall Hospital considers that this data is as described for the following
reasons



All clinical staff are aware of the need for VTE assessment
Clinical care pathways direct the staff member to ensure completion
Excellent communication with Consultants to ensure compliance.
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

To ensure patients’ VTE requirements are assessed and patients receive
appropriate prophylaxis.
Quality Accounts 2013/14
Page 31 of 43
C.Difficile rates per 100,000 bed days
Period
Best
Worst
Average
Period
New Hall
2012/13
Several
0
RNA
58.2
Eng
22.2
2012/13
NVC09
0.0
2013/14
Several
0
RVW
30.8
Eng
17.3
2013/14
NVC09
0.0
New Hall Hospital considers that this data is as described for the following
reasons


We have a good record in infection prevention and control
Antimicrobial prescribing is in line with Ramsay policy and CCG formulary
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

To ensure patients’ VTE requirements are assessed and patients receive
appropriate prophylaxis.
Incident rate, patient safety
Period
Best
Worst
Average
Period
New Hall
2012/13
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
NVC09
6.56
2013/14
RRF
2.0
RAT
85.6
Eng
14.8
2013/14
NVC09
6.7
New Hall Hospital considers that this data is as described for the following
reasons


We provide elective and non emergency elective care for spinal patients
with significant co-morbidities.
There is an effective pre admission process to ensure patients condition is
optimised prior to surgery
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service


To continue ensure all patient safety incidents are reviewed and analysed
to identify areas of concern and action plan as required
Ensure patients are treated in a safe and comfortable environment and
that staff are responsive to their needs.
Quality Accounts 2013/14
Page 32 of 43
Friends and Family Test
Period
Best
Worst
Average
Period
New Hall
Jan-14
Several
100
RPA02
27
Eng
73
2012/13
NVC09
86
Feb-14
Several
100
RPA02
18
Eng
73
2013/14
NVC09
100
New Hall Hospital considers that this data is as described for the following
reasons


Actively encourage patients to undertake the friends and family test
The test has now been expanded to outpatients to gain an overall picture
of the hospital rather than just inpatients.
New Hall Hospital intends to take the following actions to improve this rate and so
the quality of its service

To continue to encourage patients to take the test
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.
Quality Accounts 2013/14
Page 33 of 43
3.2.1 Infection prevention and control
New 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.
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:

Comprehensive infection control programme of staff education and
competency assessments including Aseptic Non Touch Technique (ANNT)

Strict adherence to Ramsay uniform policy for all staff including bare below
elbows for all Consultant staff

Hand gel dispensers are available at the end of every patient bed and
instructions on how to the use the gel correctly displayed

The hospital has an Infection Control Commitee led by a Consultant
Microbiologist. This meets quarterly and reports to the Clinical Governance
Commitee and corporate infection control commitee.

Spots checks on all staff of hand hygiene practice using a UV light box.

A regular programme of audit covering all aspects of infection control as
well as spot checks on cleaning practices by the Senior Management
Team.
Quality Accounts 2013/14
Page 34 of 43
Infection Rates
(percentage of Admissiosns)
Infection Rates
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2011/12
2012/13
2013/14
New Hall Hospital
As shown in the graph our infections rates remain very low and are reducing year
on year despite accepting more complex patients and non elective non
emergency cases
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 New 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.
The chart below shows the four domains of the assessment against the overall
Ramsay score.
Site Name
Site Type
NEW HALL
HOSPITAL
Acute/Specialist
Ramsay Overall Average
Cleanliness
Food and
Hydration
95.96%
Privacy,
Dignity
and
Wellbeing
87.69%
Condition
Appearance
and
Maintenance
85.29%
93.71%
95.95%
89.21%
88.62%
89.45%
New Hall has had a significant refurbishment programme since this PLACE audit
took place and will strive to improve in all domains.
Quality Accounts 2013/14
Page 35 of 43
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.
Activities during 2013/14





All incidents recorded in a timely manner on Ramsay electronic risk
reporting system (riskman). This are reviewed and analysed by the senior
management team, at Clinical Governance and health and safety
meetings. Actions plans are developed in response to concerns raised and
shared with appropriate staff.
CCTV is now insitu that covers all external areas of the hospital
An automatic bed pusher is now in use to assist with manual handling.
Staff undergo a comprehensive programme in manual handling activities,
fire and security awareness.
All patients beds are now electric allowing greater control for staff and
patients and reducing the need for manual handling.
3.3 Clinical effectiveness
New Hall 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.
Quality Accounts 2013/14
Page 36 of 43
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
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2011/12
2012/13
2013/14
New Hall Hospital
As can be seen by the graph above the number of returns to theatre has
increased year on year but is still low. The increase may be due to the increasing
complexities of the procedures undertaken. All returns to theatre are entered onto
riskman and analysed for trends by the senior management team and Clinical
Governance teams. All returns to theatre will continue to be monitored and
actions taken as required.
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
Quality Accounts 2013/14
Page 37 of 43
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:










Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently
of the hospital so we receive a true reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked
are used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Manager within 48hrs of receiving them so that a response can be made to the
patient as soon as possible.
Quality Accounts 2013/14
Page 38 of 43
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
100
80
60
40
94.7
93.0
2012/13
2013/14
20
0
New Hall Hospital
As can be seen in the above graph our patient satisfaction rate has dropped
slightly but is still good. This may be due to the significant disruption due to the
extensive refurbishment undertaken.
3.4 New Hall Hospital Case Study
In order to understand what we can do better from a patient perspective we have
set up a patient participation group. This is where a cross section of people who
have used the service are invited to discuss their and that of their relatives/carers
experience during their hospital stay. As a result we will be able to develop action
plans that take into account their perspective of care given and make positive
changes as required.
We are committed to continuing to engage with patients, staff, Consultants and
other relevant stakeholders to continually improve the quality of service we
provide and patient experience.
Quality Accounts 2013/14
Page 39 of 43
Appendix 1
Services covered by this quality account
New Hall Hospital
New Hall Hospital/Treatment Centre has 48 beds
and 3 theatres (2 with laminar flow).
Patients’ requiring level 2 care are treated and cared
for by a well trained team of staff in a dedicated level 2
facility.
New Hall provides care and treatment for children over the age of 16. We see
children in OPD for consultation only. On site facilities include Radiology,
Physiotherapy, Mobile MRI and Pharmacy. We also provide a satellite out patient
services at Dorset and Poole County Hospital
New Hall Hospital is set in beautiful grounds. Consideration for our patients is at
the heart of everything that we do. We are constantly seeking new ways of
working and bringing in fresh clinical practices that will improve outcomes for our
patients. Our approach to service delivery is courteous and professional.
Regulated Activities
Location: New Hall Hospital, Bodenham, Salisbury, Wiltshire SP5 4EY Tel:
01722 435142
Registered Manager: Fiona Taylor
Fiona.taylor@ramsayhealth.co.uk
Regulated Activities – New Hall Hospital
Treatment of
Disease,
Disorder
Or injury
Services Provided
Peoples Needs Met for:
Bariatrics, Dermatology, General medicine, Neurology,
Oncology, Paediatrics (outpatient consults only), Pain
management, Physiotherapy, Psychiatry (outpatients
only), Psychology, Orthopaedic medicine,
Rheumatology, Sports Medicine
Satellite Out patient services being carried out at Dorset
County Hospital and Poole Hospital for Dorset PCT
Outreach clinics at Blandford Community Hospital for
spinal and orthopaedic consultation.
All adults 18 yrs and over, and young persons 16-18 yrs
Children 0-16 yrs outpatient consultation only
Quality Accounts 2013/14
Page 40 of 43
Surgical
Procedures
Bariatrics, Cosmetics, Dermatology, Ear, Nose and
Throat (ENT), Gastrointestinal, General surgery,
Gynaecology, Ophthalmic, Orthopaedic, Oral
maxillofacial, Urological, Ambulatory, Day and Inpatient
Surgery
All adults 18 yrs and over, young persons 16-18yrs
excluding:












Patients with blood disorders (haemophilia, sickle cell,
thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA screen
are deferred until negative
Patients who are likely to need ventilatory support
post operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to ITU
post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or dyspnoea at
rest)
Poorly controlled asthma (needing oral steroids or has
had frequent hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (Limitations on normal
activity e.g. 1 flight of stairs or angina at rest)
CVA in last 6 months BMI >340 (non bariatrics)
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
Family
Planning
Services
GI physiology, Imaging services, Phlebotomy,
Endoscopy, Urinary, Urodynamics, Screening and
Specimen collection. Satellite Outpatient services
carried out at Dorset County Hospital and Poole
Hospital for Dorset PCT
All adults 18 yrs and over, young persons 3-18yrs
Gynaecology patient pathway, insertion and removal of
inter uterine devices for medical as well as
contraception purposes
All adults 18 years and over as clinically indicated
Quality Accounts 2013/14
Page 41 of 43
Appendix 2 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
Page 42 of 43
New 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:
01722 422333
or
http://www.newhallhospital.co.uk
Quality Accounts 2013/14
Page 43 of 43