Park Hill Hospital
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
3
Introduction to our Quality Account
4
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
5
1.2
Hospital accountability statement
7
PART 2
2.1
Priorities for Improvement
9
2.1.1 Review of clinical priorities 2013/14 (looking back)
10
2.1.2 Clinical Priorities for 2014/15 (looking forward)
11
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
14
2.2.2 Participation in Clinical Audit
17
2.2.3 Participation in Research
18
2.2.4 Goals agreed with Commissioners
19
2.2.5 Statement from the Care Quality Commission
20
2.2.6 Statement on Data Quality
21
2.2.7 Stakeholders views on 2010/11 Quality Accounts
23
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
24
3.2
Patient Safety
34
3.3
Clinical Effectiveness
39
3.4
Patient Experience
40
3.5
Case Study
44
Appendix 1 – Services Covered by this Quality Account
45
Appendix 2 – Clinical Audits
46
Welcome to Ramsay Health Care UK
Park Hill Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group, was established in 1964 and has grown to become
a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with
a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of
NHS patient episodes of care each month working seamlessly with other healthcare
providers in the locality including GPs, Clinical Commissioning Group.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is our number one goal. This relies not only on excellent
medical and clinical leadership in our hospitals but also upon an organisation wide
commitment to drive year on year improvement in patient satisfaction and clinical
outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is not about
reliance on one person or a small group of people to be responsible and accountable
for our performance. It is essential that we establish an organisational culture that
puts the patient at the centre of everything we do and as a long standing and major
provider of healthcare services across the world, Ramsay has a very strong track
record as a safe and responsible healthcare provider and we are proud to share our
results.
Across Ramsay we nurture the teamwork and professionalism on which excellence in
clinical practice depends. We value our people and with every year we set our targets
higher, working on every aspect of our service to bring a continuing stream of
improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
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Introduction to our Quality Account
This Quality Account is Park Hill Hospitals 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
Dawn Abbott, General Manager
Park Hill Hospital
“Park Hill Hospital understands that you have a choice and is committed to
being the leading healthcare provider of choice by delivering high quality care
and outcomes for patients.”
This is the third Quality Account to be submitted by Park Hill 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 and improve the patient’s journey with the aim of becoming
the healthcare provider of choice for all patients.
We are aware that patients can be nervous about coming into hospital and
understand that providing reassurance is important to you the patient and your
family. This starts with patient safety, which is our highest priority. To this end we
recruit, induct and train our team to the highest standard in all aspects of care. This
approach extends to family and visitors in ensuring they are made to feel welcome at
Park Hill Hospital.
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Park Hill Hospital is committed to ensuring that patients are kept fully informed about
their treatment, which is also a significant factor associated with improving treatment
outcomes. We involve our patients in treatment decisions at the earliest stage so that
the options and benefits are fully discussed before patients consent to treatment. Our
medical and clinical teams recognise the importance of devoting time preparing
patients for surgery, which not only reduces risk but also improves patient
understanding and confidence, reduces anxiety, improves rates of recovery and
shortens length of hospital stay.
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.
Park Hill Hospital is accustomed to the disciplines of regulatory and contractual
requirements to assure healthcare commissioners of our clinical performance and to
report complaints and serious incidents to regulators and commissioners. We also
maintain a Risk Register and systematically review specific actions to achieve risk
reduction.
Park Hill Hospital continually achieves consistent patient satisfaction scores of over
94% recommendation to others and for overall satisfaction and at time of writing is
showing one of the highest Friends and Families scores for any hospital Private or
NHS. By analysing the results throughout the year, we constantly seek ways to
further improve the patient experience.
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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.
Dawn Abbott
General Manager
Park Hill Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Stephen Bruce Bittiner, MAC Chair
Antony Wilkinson, Clinical Governance Committee Chair
Stefan Andrejczuk, Regional Director
Doncaster Clinical Commissioning Group
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Welcome to Park Hill Hospital
Park Hill Hospital is one of South Yorkshire’s leading private hospitals with an
excellent reputation for delivering high quality healthcare treatments and services.
Located on the site of the Doncaster Royal Infirmary, Park Hill Hospital opened in
April 1995. The ward consists of 21 beds, 17 of which are in single rooms, all with ensuite facility. The outpatient department consists of 6 consulting rooms and a minor
procedure treatment area.
The hospital provides a full range of quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months, the hospital has treated 3,052 patients, 66% of
which were treated under the care of the NHS. All NHS patients treated at the
hospital must be over 18 years of age as defined by the Standard Contract.
Currently, over 100 specialist Consultants work from the hospital, supported by a
team of 59 staff (31 nursing/physiotherapy and 26 administration/support services).
We also have a Resident Medical Officer (RMO) 24 hour emergency support.
Park Hill Hospital has a very close working relationship with Doncaster & Bassetlaw
Hospitals NHS Foundation Trust, and has access to support services through various
service level agreements with the Trust.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Park Hill Hospital develops an operational plan to set objectives
for the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to
improve clinical safety and standards by a systematic process of governance
including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
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Priorities for Improvement
2.1.1 A review of clinical priorities 2012/13 (looking back)
1. Information Security – Park Hill Hospital achieved the information security
accreditation ISO27001. Our aim is to ensure that all staff maintain the current
high compliance rates, by continually raising awareness of the importance of
data protection and information security.
Action Taken:
Information Governance continuing assessment was carried out on
29th April 2013. The areas assessed during the course of the visit were
generally found to be effective.
1 minor non-conformity from this assessment and 8 observations
made.
There were no outstanding non-conformities to review from Park
Hill’s previous assessment.
Information Governance is continually discussed and monitored at the
local Health & Safety Committee.
72% of staff completed Information Security eLearning training.
70% of staff attended in-house refresher update training.
2. Staff competencies - Ensuring well trained, competent staff are available to
care for patients is a high priority at Park Hill Hospital. We continue to develop
our Health Care Assistants in theatre to attain City & Guilds Level 3 in Health
Care. This ensures they hold the knowledge skills to support the delivery of
care to our patients. Ramsay Health Care has developed a Clinical Skills
Portfolio specifically for Health Care Assistants. The Clinical Skills Portfolio is
a tool to measure our Health Care Assistants ability to recognise and respond
to patients undergoing clinical procedures, confidently and competently.
Following the Cavendish report in July 2013 and recommendations made
Ramsay Healthcare have implemented core competencies for health care
assistants (HCA’s) in order to ensure the care that they provide is safe and
consistent. Park Hill hospital work closely with North Nottinghamshire College
who provide NVQ training for support staff at levels one, two and three.
Health care assistant staff members are routinely assessed on site and
support is offered by both the college and the clinic to encourage further
development. Ramsay Healthcare has recently introduced a HCA core
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competencies training package for further development. Development is
discussed at the induction stage, competencies are observed by a mentor on
a regular basis to ensure safe effective practice is achieved and at
professional development reviews which are instigated on a yearly basis.
In order to ensure the ongoing support of students (Adult Nursing, Operating
Department Practitioners, and Physiotherapists) four staff members have
successfully completed a mentorship course with Sheffield Hallam University.
3. National Joint Registry – Park Hill Hospital aims to improve its submission
rate to the National Joint Register for 2013/14, as, during 2012/13 our
submission rate was 93%, which is just below the target (95%).
Action Taken:
Park Hill’s submission rate for 2013/2014 is 98.4%, an increase of 5.4%
on last year.
Park Hill Hospital has taken the following actions to improve upon last year’s
score so the quality of its services can be monitored and improved upon by:
•Raising awareness of the importance of patient participation by further staff
development of the clinical team
•Patients are encouraged to complete the survey to ensure a high return rate
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Clinical Effectiveness
Park Hill Hospital has a Clinical Governance team and committee that meet
regularly throughout the year to monitor quality and effectiveness of care.
Clinical effectiveness was chosen in order to evidence that Park Hill are
striving to strengthen governance by encompassing the following key areas:
1.
2.
3.
4.
5.
Improved incident reporting
Continual & spot Audit
NHS Safety Thermometer Audit
PROMS ( Patient reported outcome measure Studies)
Cavendish Report and the strengthening of Health Care Assistant
Roles
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Incident Reporting
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.
Incident and near-miss reporting is encouraged to ensure effective learning in a
no blame culture. Park Hill Hospital intend to instigate Lessons Learnt forums
following incidents ensuring staff fully understand lessons learnt and plan
actions accordingly in order to address issues identified. The outcomes will
then be reported onto the Riskman site and attached to individual incidents
evidencing a robust investigation and satisfactory outcome.
Patient Experience
Park Hill Hospital committed to improving upon the service that our patients
experience. We endeavour to be the health care provider of choice for all our
patients. In order to accomplish this we aim to measuring feedback from
patients about their experience, clinical treatment and clinical outcomes.
We have chosen patient experience to evidence compliance in the following key
areas:
1. Patient Feedback
2. Customer Excellence Training
3. Telephone Handling
We intend to continue to monitor patient feedback in order to build upon the
patient experience at Park Hill Hospital. We pride ourselves as being the
hospital of choice for all our patients and fully intend to continue to provide a
first class service.
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Customer Excellence / Mandatory Training
Ramsay Healthcare has instigated a Customer Care Excellence service training
initiative throughout all Ramsay hospitals.
Park Hill Hospital has a local champion who attended training corporately; the
first training programme for customer care excellence was instigated locally in
August 2012.
In order to raise continued staff awareness a further training session was
incorporated into the mandatory training programme as a refresher session.
The second stage of the corporate training programme is set to commence in
June 2014. This training enforces a raised awareness of patient perception and
expectation; reminding staff of the importance of consistent excellence in
customer care. The results of this training can be monitored through the patient
feedback satisfaction survey and the friends and family test. This training
programme will be instigated monthly and encompass all staff within the
hospital.
Patient Safety
Park Hill Hospital is a progressive hospital focussed on improving its
performance every year, particularly with regard to patient safety. Risks to
patient safety are identified 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.
We have chosen patient safety to evidence that the Yorkshire Clinic are
committed to improve upon patient safety initiatives already embedded within
the hospital by encompassing the following key areas:
1.
2.
3.
4.
5.
Falls
Never Events
Consent
Vulnerable adults
Prevent
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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 Park Hill Hospital provided and/or subcontracted four NHS services.
Park Hill Hospital has reviewed all the data available to them on the quality of care in
all of these NHS services.
Orthopaedics - including Podiatry
General Surgery
Pain Management
Minor Plastics
The income generated by the NHS services reviewed in 1st April 2013 to 31st March
14 represents 100% per cent of the total income generated from the provision of NHS
services by Park Hill Hospital for 1st 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:
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Human Resources
Clinical Headcount
Total WTE Nursing (RN & HCA)
Total Headcount
Rolling Sickness Absence
Rolling Employee Turnover
Number of Significant Staff Injuries
(RIDDOR reportable)
31 March
2012
31
28.58
53
4.18%
14.5%
0
31 March
2013
32
28.78
55
4.62%
13.2%
0
31 March
2014
30
27.51
56
5.51%
10.9%
0
The ratio of Qualified Nurses to Health Care Assistants has altered recently due to
improvements in training and recruitment of Health Care Assistants to provide
additional competency skilled ability to more effectively support the Registered
Nurses to deliver a higher quality of care.
All staff members at Park Hill must complete a Mandatory training programme which
includes clinical and non-clinical aspects. Staff compliance is recorded and the table
below shows current compliance (as at March 2014). Training is provided internally
and externally, the topics covered are:
Course Type
Basic Life Support
Safeguarding Children Elearning
Customer Care
Data Protection Elearning
Fire Safety Training
Induction
Health and Safety Elearning
Infection Control Elearning
% Trained
80.4%
73.2%
76.8%
78.6%
67.9%
100.0%
75.0%
80.4%
Information Security
Manual Handling
Safeguarding of Vulnerable Adults SOVA
Equality Diversity
Food Hygiene
Intermediate Life Support
76.8%
69.6%
67.9%
73.2%
12.5%
27.8%
Blood Transfusion update / training
TOTAL
45.8%
71.7%
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Staff appraisals are carried out annually and objectives set for the new financial year.
Any additional training needs are identified by the staff and their line managers. At
Park Hill Hospital we believe that training and professional development is a core
activity, providing opportunities for our staff to learn, to develop and succeed whilst
fully supporting our business priorities.
Ramsay Health Care developed the Ramsay Academy which reflects the
organisations continuing passion for ensuring that all staff have the chance to
achieve their full potential whilst working for Ramsay Health Care.
The Ramsay Academy Prospectus provides training opportunities in the following
areas:
Mandatory Training
IT & Business Processes
Personal Effectiveness
Clinical
Organisational Development
Management Development Framework
Staff satisfaction, derived from The Best Companies, Employee Surveys was
completed in November 2013. This was completed by 77% of Park Hill staff and our
Satisfaction Score overall was 5.09%. The maximum score possible was 7 and the
minimum 1. This was an excellent result for Park Hill Hospital who achieved the
highest satisfaction score of all the 37 units within Ramsay Health Care UK and was
also an increase of 0.2% from the previous survey.
From these results staff at Park Hill are happy to work for Ramsay Health Care, and
enjoy working within their respective teams.
Site
Highest in Group - Director/Board
General Manager
Corporate Swedbank
Highest Hospital - Park Hill
Newhall Hospital
Blakelands Hospital
Corporate Bedford
Ramsay Health Care Average
Lowest in Group
2014
5.82
5.38
5.14
5.09
4.89
4.86
4.85
4.54
3.86
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2.2.2 Participation in clinical audit
During 1st April 2013 to 31st March 2014 Park Hill Hospital participated in 4 national
clinical audits and 1 national confidential enquiries of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Park Hill 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.
The national clinical audits and national confidential enquiries that Park Hill Hospital
participated in, and for which data collection was completed during 1 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
98.4
100
Medical and surgical clinical outcome review programme: National
confidential enquiry into patient outcome and death
100
SSIS – Surgical Site Surveillance
100
NHS Safety Thermometer
100
The reports of the applicable national clinical audits from 1st April 2013 to 31st March
11 2014 were reviewed by the Clinical Governance Committee and Park Hill Hospital
intends to take the following actions to improve the quality of healthcare provided.
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Local Audits
The reports of 70 local clinical audits from 1st April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Park Hill Hospital intends to
take the following actions to improve the quality of healthcare provided. The clinical
audit schedule can be found in Appendix 2.
Infection Prevention Audits: Park Hill Hospital has followed the corporate
audit programme throughout the year and results have shown improvement in
hand hygiene and care of peripheral venous catheter with scores rising to
100% respectively.
WHO – Surgical Safety Check Audit: This is incorporated into the care
record for every patient and there is an additional audit to monitor compliance
with the checklist. The audit assesses that clinical staff are routinely checking
that the correct patient, receives the correct surgery on the correct site, and
the patient has been appropriately prepared and consented for the procedure
planned.
Consent Audit: Assesses the consent process in 2 stages. Stage one
ensures that patients are provided with sufficient information to provide
informed consent. Stage two confirms that the patient is happy to proceed
having had time to consider the information provided
Medical Records: - Pre-operative telephone calls have been implemented to
be made within 48 hours of admission by a member of the clinical team, to
confirm admission and discharge plan. These are audited regularly and
encouraging improvements month on month.
Physiotherapy: – both inpatient and outpatient physiotherapy notes have
been amalgamated into the main medical records.
2.2.3 Participation in Research
There were no patients receiving NHS services provided or sub-contracted by
Park Hill Hospital in 2013/14 that were recruited during that period 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 Park Hill Hospital’s income in from 1st April 2013 to 31st March 2014
was conditional on achieving quality improvement and innovation goals agreed with
Park Hill Hospital and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the Commissioning for
Quality and Innovation payment framework.
CQUIN SCHEME:
INDICATOR
1. National Friends
and Family
2. National Safety
Thermometer
3. National VTE
GOAL
QUALITY DOMAIN
Full delivery of the
national set
milestones.
Response rate that
achieves an
improved response
rate in Qtr 4 from
Qtr 123 and
increasing to at
least 20%
A completed
survey for each
month submitted to
data centre and a
detailed report
provided to the
commissioners
Patient Experience
Achievement of at
least 95% of
patients to have
had a VTE
assessment on
admission and a
root cause analysis
to be carried out on
all cases of hospital
associated
thrombosis.
Safety,
Effectiveness
Safety,
Effectiveness
DESCRIPTION OF
INDICATOR
To improve the
experience of the
patient in line with
Domain 4 of the NHS
Outcomes Framework.
To collect data on the
following three
elements of the NHS
Thermometer:
Pressure ulcers
Falls
Urinary tract
infection patients
with a catheter
Achievement of agreed
target for both risk
assessment and root
cause analysis for each
month.
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2.2.5 Statements from the Care Quality Commission (CQC)
Park Hill Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions.
Park Hill Hospital has not participated in any special reviews or investigations by the
CQC during the reporting period.
Park Hill was last inspected on 30th January 2014, this was an unannounced visit.
An Inspector attended the site visit and inspected 5 standards:
Consent to care and treatment
Care and Welfare of people who use services
Cleanliness and Infection Control
Requirements relating to workers
Records
Park Hill was successfully fully compliant with each of the standards inspected and
some of the patient feedback received by the inspector on the day;
“You are not a number you are treated as an individual”.
“You can’t fault the staff or care provided it is excellent”.
“All the staff are great they look after us very well”.
“I have been very pleased with the service; I have been looked after properly”.
“Staff speak to you in terms you understand, even the consultants”.
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2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your Data
Quality
Park Hill hospital will be taking the following actions to improve data quality.
Good quality information underpins the effective delivery of patient care and is
essential if improvements in quality of care are to be made. Improving data quality,
which includes the quality of ethnicity and other equality data, will thus improve
patient care and improve value for money. On induction our staff are trained on how
to obtain and input data correctly onto our electronic systems and also how to handle
it confidentially, staff are monitored on correct data capture via internal reports and
data quality training is updated regularly throughout the hospital.
At Park Hill hospital data quality is one of our highest priorities to ensure we produce
clean and accurate electronic data which we can use to monitor and improve our
quality of care and service. Throughout the year we have updated and strengthened
our processes to capture data in a timely manner and to audit data prior to
submission. We are constantly looking to improve data capture and reporting
processes supported by a dedicated corporate quality team.
NHS Number and General Medical Practice Code Validity
Park Hill Hospital submitted records during 2013/14 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are
included in the latest published data. The percentage of records in the published data
which included:
The patient’s valid NHS number:
99.97% for admitted patient care;
99.96 for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
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).
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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
Annual clinical coding audit performed by Julie Gibbs, National Clinical Coding Lead,
with excellent results, as per table below. All were above the accepted levels of
attainment for Information Governance for clinical coding audit.
Audit February 2014 Park Hill Hospital Information Governance Attainment Requirement 505 Levels
Primary Diagnosis
100% correct
Secondary Diagnosis
96.55 % correct
Primary Procedure
100% correct
Secondary Procedure 98.73% correct
Park Hill 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
Our Quality Account was submitted to:
Stephen Bruce Bittiner, MAC Chair
Antony Wilkinson, Clinical Governance Committee Chair
Stefan Andrejczuk, Regional Director
Doncaster Clinical Commissioning Group
No comments were received.
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
General Manager/Matron, Dawn Abbott
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our performance
on many levels, we reflect on the valuable feedback we receive from our patients
about the outcomes of their treatment and also reflect on professional opinion
received from our doctors, our clinical staff, regulators and commissioners. We listen
where concerns or suggestions have been raised and, in this account, we have set
out our track record as well as our plan for more improvements in the coming year.
This is a discipline we vigorously support, always driving this cycle of continuous
improvement in our hospitals and addressing public concern about standards in
healthcare, be these about our commitments to providing compassionate patient
care, assurance about patient privacy and dignity, hospital safety and good outcomes
of treatment. We believe in being open and honest where outcomes and experience
fail to meet patient expectation so we take action, learn, improve and implement the
change and deliver great care and optimum experience for our patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care, clinicians
are enabled to provide that care and the organisation can satisfy itself that we are
doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance systems
in the organisation and should not be seen as a “stand-alone” activity.
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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
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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.
3.1 The Core Quality Account indicators
Expected death
Period
Best
Worst
Average
Apr12 - Mar13 RBA 0.1 RWH 44.0 Eng 20.4
Jul12 - Jun13
RBA 0.0 RWH 44.1 Eng 20.2
Period
Park Hill
2012/13 NVC14 0.0
2013/14 NVC14 0.0
Related NHS Outcomes
Framework Domain
The data made available to the National
1: Preventing People from dying
Health Service trust or NHS foundation trust by prematurely
the Health and Social Care Information Centre 2: Enhancing quality of life for
with regard to—
people with long-term conditions
(a) the value and banding of the summary
hospital-level mortality indicator (“SHMI”) for
the trust for the reporting period; and
(b) The percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level for the trust for the reporting
period.
*The palliative care indicator is a contextual
indicator.
Prescribed Information
Park Hill considers that this data is as described for the following reasons:
In addition to providing surgical care and treatment, Park Hill Hospital has no
recorded deaths in 2012/13 and 2013/14.
Quality Accounts 2013/14
Page 26 of 47
PROMS (Patient reported outcome measures)
PROMS:
Period
Hernia Apr12 - Mar13
Apr13 - Sep13
Best
NT415 0.157
RTG
0.138
Worst
NVC27 0.015
RNA
0.019
Average
Eng
0.085
Eng
0.086
Period
Apr12 - Mar13
Apr13 - Sep13
Park Hill
NVC14
NVC14
PROMS:
Period
Veins Apr12 - Mar13
Apr13 - Sep13
Best
RV8
5.14
RTD
-9.74
Worst
NT350 -15.92
RLN
-10.52
Average
Period
Eng
-8.374 Apr12 - Mar13
Eng
-9.46 Apr13 - Sep13
Park Hill
NVC14
NVC14
PROMS:
Period
Hips Apr12 - Mar13
Apr13 - Sep13
Best
NT209 24.68
NT318 25.44
Worst
RKE
17.21
RHQ
18.34
Average
Eng
21.32
Eng
21.61
Period
Apr12 - Mar13
Apr13 - Sep13
Park Hill
NVC14
*
NVC14
*
PROMS:
Period
Knees Apr12 - Mar13
Apr13 - Sep13
Best
NT219 20.37
RDE
20.09
Worst
RAP
12.46
RM1
14.32
Average
Eng
16.01
Eng
16.74
Period
Apr12 - Mar13
Apr13 - Sep13
Park Hill
NVC14
*
NVC14
*
(* denotes insufficient data for publishing from the 2 questionnaires following case-mix adjustment by the NHS
data centre, which could be as a result of insufficient return of one of both of the questionnaires, in completed
questionnaires, NHS number omission)
The data made available to the National
3: Helping people to recover
Health Service trust or NHS foundation trust by from episodes of ill health or
the Health and Social Care Information Centre following injury
with regard to the trust’s patient reported
outcome measures scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery,
during the reporting period.
Park Hill hospital considers that this data is as described for the following
reasons:
Park Hill hospital participates in the Department of Health PROM’s survey for hip and
knee replacement surgical procedures for NHS & private patients. Compliance for
PROM’s participation for Park Hill hospital, is above the national average.
Quality Accounts 2013/14
Page 27 of 47
Readmissions
Period
2010/11
2011/12
Best
RF4
0.0
RF4
0.0
Worst
RYR
15.8
RYR
15.8
Average
Eng
11.04
Eng
11.08
Period
2012/13
2013/14
Park Hill
NVC14
0
NVC14
0
The data made available to the National
3: Helping people to recover
Health Service trust or NHS foundation trust by from episodes of ill health or
the Health and Social Care Information Centre following injury
with regard to the percentage of patients
aged—
(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital which forms part of
the trust within 28 days of being discharged
from a hospital which forms part of the trust
during the reporting period.
Park Hill Hospital considers that this data is as described for the following
reasons:
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness & outcomes. As with return to theatre, any emerging trend identified
with a specific surgical operation or surgical team may identify contributory factors to
be addressed. Ramsay rates of readmission remain very low and this, in part, is due
to sound clinical practice & governance ensuring patients are not discharged home
too early after treatment, are independently mobile and that patients are fully
informed of individual discharge information.
Quality Accounts 2013/14
Page 28 of 47
Responsiveness to Personal Needs of Patients
Period
2011/12
2012/13
Best
RYR
73.3
RYR
75.9
Worst
RF4
67.4
RJ6
68.0
Average
Eng
75.6
Eng
76.5
Period
2012/13
2013/14
Park Hill
NVC14
91.3
NVC14
92.5
The data made available to the National
4: Ensuring that people have a
Health Service trust or NHS foundation trust by positive experience of care
the Health and Social Care Information Centre
with regard to the trust’s responsiveness to the
personal needs of its patients during the
reporting period.
Park Hill Hospital considers that this data is as described for the following
reasons:
Feedback from patients regarding their experience at Park Hill Hospital is
encouraged and is essential to inform our staff how care can be enhanced or
adjusted to meet individual patient satisfaction. All positive feedback is relayed to the
relevant staff to reinforce good practice and behaviour – letters and cards are
recorded on the Riskman system and displayed for staff to see on notice boards.
Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative comments or suggestions for improvement are also communicated 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. Every complaint
received is given immediate attention of the General Manager/Matron on the day it is
received, following which a thorough investigation is commenced into the concerns
raised as per Ramsay Complaints Policy.
Patient experiences are received from the various routes listed below, and are
regular agenda items on Local Governance Committees for discussion, trend
analysis and further actions as necessary. Escalation and further reporting to the
Ramsay Corporate Governance Team, our stakeholders and regulatory bodies
occurs as required in line with Ramsay Healthcare and Department of Health policy.
Quality Accounts 2013/14
Page 29 of 47
Park Hill Hospital has taken the following actions to improve this score, and so
the quality of its services, by:
Feedback regarding the patient’s experience is received through the following routes:
Patient satisfaction surveys
We value your opinion questionnaire leaflet
Direct verbal feedback to Ramsay staff.
Internal Ramsay audit /inspection processes.
CQC inspection feedback.
Written feedback via letters/emails/complaints
PROMs surveys
Care pathways – patients are encouraged to read and participate in their
plan of care.
Annual PLACE patient audit
Venous Thromboembolism (VTE)
Period
Best
Worst
Average
Period
Park Hill
13/14 Q3 Several 100% NT244 63.2% Eng 95.8%
13/14 Q3 NVC14 99.8%
13/14 Q4 Several 100% NT205 67.0% Eng 96.0%
13/14 Q4 NVC14 99.4%
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the percentage of patients who
were admitted to hospital and who were risk
assessed for venous thromboembolism during
the reporting period.
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Park Hill Hospital considers that this data is as described for the following
reasons:
Park Hill Hospital carry out a VTE risk assessment on all admitted patients as per
Ramsay policy which is based upon the National Institute for Clinical Excellence
(NICE) Guidance 2010. Our pre assessment team complete a VTE competency
assessment via the Department of Health on line assessment tool.
Quality Accounts 2013/14
Page 30 of 47
Park Hill Hospital has taken the following actions to improve upon and
maintain this score by:
Completion of Corporate audits, incident investigation, reporting, root cause
and gap analysis
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Also through local Medical advisory committee and Risk
management meetings.
Strict adherence to infection control policies
Clostridium Difficile Infection
Period
Best
2012/13 Several 0
Worst
RNA
Average
Period
Park Hill
58.2 Eng 22.2
2012/13 NVC14 0.0
2013/14 Several 0 RVW 30.8 Eng 17.3
2013/14 NVC14 0.0
The data made available to the
National Health Service trust or NHS
foundation trust by the Health and
Social Care Information Centre with
regard to the rate per 100,000 bed
days of cases of C difficile infection
reported within the trust amongst
patients aged 2 or over during the
reporting period.
5: Treating and caring for people in a
safe environment and protecting them
from avoidable harm
Park Hill Hospital considers that this data is as described for the following
reasons:
An annual strategy for Infection Prevention and Control (IPC) is developed at a
corporate level by the Group IPC and policies are revised and redeployed every two
years. IPC programmes are designed to bring about improvements in performance
and practice.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and best clinical practice.
Healthcare associated infections (HCAI) are acquired as a result of healthcare
intervention. High standards of Infection Prevention and Control practice minimise the
risk of occurrence of HCAIs.
Quality Accounts 2013/14
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Park Hill Hospital has taken the following actions to maintain this score, and so
the quality of its services, by:
Infection Control issues are discussed and reviewed at the local Clinical
Governance Committee which consists of representatives from all areas of the
hospital. The committee meets quarterly to oversee implementation of
corporate policies and National guidance and review clinical audit & practice.
Minutes from local meetings develop and review action plans to address
issues identified in both the corporate and local annual strategy/plan for
infection control.
All staff undertake mandatory infection prevention and control (IPC) training
annually plus the clinical staff receive bi-annual Infection Prevention and
Control training/updates from our Consultant Microbiologist
Completion of Corporate clinical audits, incident reporting, identifying trends
and identification of further training requirements
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Also through local Medical advisory committee and Risk
management meetings.
Incident Rate and Patient Safety
Period
Best
2011/12 RP6 2.6
Worst
TAJ
Average
Period
Park Hill
84.4 Eng 13.5
2012/13 NVC14 13.3
2012/13 RRF 2.0 RAT 85.6 Eng 14.8
2013/14 NVC14 6.37
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the number and, where
available, rate of patient safety incidents
reported within the trust during the reporting
period, and the number and percentage of
such patient safety incidents that resulted in
severe harm or death
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Park Hill Hospital considers that this data is as described for the following
reasons:
Park Hill Hospital strives to report any incidents or near misses in real time through
an electronic incident reporting tool called “ Riskman”. Every incident is promptly
reviewed by General Manager/Matron and an investigation process, root cause
analysis and action plan implemented where appropriate.
Quality Accounts 2013/14
Page 32 of 47
The Riskman system immediately reports incidents directly to the Corporate Risk
Management Team allowing the identification of trends at Park Hill Hospital and
throughout the Ramsay organisation to further identify trends and outlying data.
Locally all incidents are reported through Risk Management and Clinical Governance
committees, learning’s and action plans are developed and implemented at a local
level to improve safety. Other National reporting mechanisms e.g. MHRA; CQC; NHS
England CAS alerts and local NHS networks are used via the Ramsay CAS alert
process to share information with frontline staff as and when this is updated.
We recognise that we have scored above the national average due to robust
processes in place however; Park Hill Hospital has taken the following actions
to improve upon this score, and so the quality of its services, by:
Maintaining a robust staff induction and mandatory training programme
Bi-Monthly Risk management and Clinical Governance meetings are
instigated where risk key performance indicators and incidents are
discussed and disseminated
Continuing staff training in risk assessment of patients specifically related to
movement and sensation of all aspects affecting limbs after surgery.
Effective implementation of the new falls risk assessment for all ward staff
Competency training provided by physiotherapists for all nurses & Health
Care assistants in specific risk assessment relating to the effects of regional
anaesthesia.
Riskman introduction training updates via web based rolling programme
Friends and Family Test
Period
Jan-14
Best
Worst
Average
Period
Park Hill
Several 100 RPA02 27 Eng 73
2012/13 NVC14 96
Feb-14 Several 100 RPA02 18 Eng 73
2013/14 NVC14 94
Friends and Family Test - Question Number
12d – Staff – The data made available by
National Health Service Trust or NHS
Foundation Trust by the Health and Social
Care Information Centre ‘If a friend or relative
needed treatment I would be happy with the
standard of care provided by this organisation'
for each acute & acute specialist trust who
took part in the staff survey.
4: Ensuring that people have a
positive experience of care
Quality Accounts 2013/14
Page 33 of 47
Park Hill considers that this data is as described for the following reasons:
A NHS-wide ‘friends and family’ test to improve patient care and identify the best
performing hospitals in England was announced in 2012 by the Prime Minister.
All patients at Park Hill Hospital are routinely invited to take part in this anonymous
survey. By completing a simple questionnaire asking whether they would recommend
our hospital to their family and friends. Scores are published on the NHS Choices
Website www.gov.uk
Alongside providing clinical excellence and safe care, patient experience is the key
measure of quality. Park Hill Hospital will use the information received from our
patients in this survey in order to improve the service we offer.
Park Hill Hospital has taken the following actions to improve this score, and so
the quality of its services, by:
Continue to raise awareness of staff of the importance of patient feedback by
highlighting results through Clinical Governance meetings, staff meetings and
Customer Care Excellence training
Review the feedback and instigate action plans to address issues highlighted
Track and record robust induction and mandatory training to ensure raised
staff awareness of the friends and family 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 following graphs:
Quality Accounts 2013/14
Page 34 of 47
3.2.1 Infection Prevention and Control
Park Hill hospital has a very low rate of hospital acquired infection and has had
no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents
year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a Corporate level Infection Prevention and Control
(IPC) Committee and group policy is revised and re-deployed every two years. Our
IPC programmes are designed to bring about improvements in performance and in
practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Infection Rates
(percentage of Admissiosns)
Infection Rates
1
0.8
0.6
0.4
0.2
0
2011/12
2012/13
2013/14
Park Hill Hospital
As can be seen in the above graph our infection rate has reduced for 2013/14.
Programmes and activities within our hospital include:
Park Hill Hospital understands that Infection Control is a core part of an effective risk
management programme, aiming to improve the quality of patient care and the
occupational health of staff, in addition to the clinical need to prevent Healthcare
Associated Infections (HCAI), and protect patients from harm.
Quality Accounts 2013/14
Page 35 of 47
Park Hill Hospitals infection control processes are coordinated and led by an
experienced Registered Nurse. Meetings are held quarterly and provide the hospital
with infection prevention advice and guidance in conjunction with Ramsay Infection
Prevention & Control Policies and Procedures and National Guidance. All staff
undertake mandatory annual e-learning and practical training sessions for Infection
Prevention. A comprehensive infection control audit programme has been maintained
throughout 2013/2014.
Audits undertaken during 2013/14 achieved average scores of: -
Hand hygiene
96%
Environment cleanliness
98.5%
Surgical site infection
100%
Peripheral venous catheter care
100%
Urinary catheter care
100%
The Infection Prevention & Control Audits have shown improvement in the following
areas: Improvement with Surgical Site Infection practices have been seen with audit
results consistently at 100% throughout 2013/14
Staff development training for surgical site Infection data collection (SSI) has
been organised to ensure robust compliance is adhered to
Action plans are in place to address all of the issues raised in all the above audits
where compliance is less than 100% and are regularly reviewed and monitored
through Clinical Governance meetings.
Issues raised from the Environmental Cleanliness Audit in 2013 were in relation to
Park Hill sinks not having mixer taps, quotes have been obtained and Park Hill will be
replacing these in 2014.
Quality Accounts 2013/14
Page 36 of 47
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 Park Hill 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.
During 2014/15 Park Hill Hospital will take part in Patient Led Assessment of the
Care Environment (PLACE) which builds on the foundation of The Patient
Environment Action Team (PEAT) assessments, with two main differences:
Patients make up at least 50% of the assessment team giving patients
a much stronger voice.
Focus is on improvement with hospitals required to report publicly and
say how they plan to improve.
The last Place audit undertaken Park Hill took part in the Patient Lead Assessment
of the Care Environment (PLACE) on 11th June 2013. Results of the audit are given
below:
Cleanliness, Condition
Food Privacy
Dignity and Wellbeing
Appearance and Maintenance
June 2013
(%)
89.81
91.07
81.58
80.17
Park Hill’s latest PLACE audit was undertaken on the 26th March 2014 by one
external assessor, 2 staff assessors and 1 patient assessor – the 2014 programme is
still underway and results will not be out until the end of June 2014.
The Report is available to download from www.efm.ic.nhs.uk
Quality Accounts 2013/14
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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.
Park Hill Hospital is linked to the wellbeing programme ensuring robust reporting and
awareness is maintained. All staff members have recently instigated a wellbeing
health surveillance programme; which is directly accessed through the Riskman
reporting system. All staff members have individual logins to ensure privacy and data
protection is maintained.
Reporting and learning from clinical incidents
Ramsay Healthcare has introduced electronic incident reporting using a system
known as Riskman. This system is accessible by all members of staff and provides
one tool for the reporting of all incidents, clinical and non-clinical. The implementation
of this tool has enabled the hospital to share incidents and ensure that there is
effective learning and action plans implemented to improve practice as required.
Park Hill Hospital has a mandatory training programme which is completed on a
yearly basis by all staff members. The training incorporates:
Customer Care
PREVENT Training
Basic Life Support
Data Protection
Infection Control
Manual Handling
Quality Accounts 2013/14
Page 38 of 47
The training sessions are split between clinical and non-clinical allowing a more
detailed approach.
Mandatory on line e-learning training is also completed on an annual basis by all staff
members who are reviewed and discussed in staff professional development reviews
which are instigated yearly with six month reviews to ensure learning and
development is on-going.
A comprehensive Health, Safety and Facilities audit was carried out at the Park Hill
Hospital by the Ramsay group Estates Manager on the 6th February 2014.
This audit returned a score of 96%. This shows an increase from the previous audit
which scored 87% compliance in 2012. This is mainly due to the audit having been
modified and now being more specific in its criteria than previous audits. The results
were passed to the Group Risk Manager prior to his upcoming visit this year.
Park Hill’s action plan from the latest audit is as follows:
Section 1.
Section 2.
Section 3.
Section 4.
Section 9
Section 11.
Section 12.
100% staff completion of mandatory e-learning
Lighting function in shared stairwell with Trust: already reported and
awaiting delivery of new light fittings
1 Bed (awaiting repair)
No record drawings and incorporate changes into system available from
Trust (awaiting a response from Trust)
Local policy for use of Hover mat device in theatre
Chefs/Engineers have received fire extinguisher training within the last 12
months - being delivered along with Fire Training at the Trust from February
2014
Clinical waste bins are not stored in patient rooms or bathrooms - to be
reviewed with Ward Manager/GM/Matron
3.3 Clinical effectiveness
Park Hill 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
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3.3.1 Return to Theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes.
Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Park Hill Hospital
3.4 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care are
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
Quality Accounts 2013/14
Page 40 of 47
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
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
Quality Accounts 2013/14
Page 41 of 47
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 as can be seen in the graph below:
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
100
80
60
40
94.6
94.0
20
0
2012/13
2013/14
Park Hill Hospital
Park Hill Hospital asks all day case and inpatient patients at registration if they
consent to Ramsay using their information to ask for feedback. Contact details of all
patients that agree to take part in the survey are them supplied to Qa Research the
week after they are discharged from hospital so they can be invited to take part.
From January 2013, the Patient Satisfaction has taken the form of an online survey
supported by a telephone survey. Previous to this, the survey was carried out on
paper with questionnaire distributed to patients at random at the time of their
discharge.
As a direct result of the comments received from patient satisfaction surveys the
following are some examples of how we endeavor to provide patients with a good
experience at Park Hill Hospital.
Quality Accounts 2013/14
Page 42 of 47
Our Chefs regularly visit patients following admission to discuss and receive
feedback on the quality of food and the options available. The catering team
work closely with the ward hostess team to ensure a consistent service is
delivered to a high standard.
A full review of menu choice has been reviewed which is to be launched midApril 2014. The new menu offers a greater choice to patients in addition to this
the new options will be listed on an updated menu card.
Relocation of hand wash gels available for patients and visitors.
Health Care staff to ensure that the emphasise the fact that they have washed
their hands prior to any patient treatment.
Quality Accounts 2013/14
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3.5 Park Hill Hospital Case Study
Park Hill Hospital has worked closely with the Doncaster & Bassetlaw Hospitals NHS
Foundation Trust since the unit opened on the site of Doncaster Royal Infirmary in
April 1995.
The two parties continue to work together to ensure that all patients requiring elective
surgery in the specialties of orthopaedic and general surgery are treated within the
Government target of 18 weeks from GP referral.
The relationship between the two hospitals has grown over the past 19 years, and
the Consultants and staff of the two units continue to work closely together ensuring
that patients in the local community receive a high quality clinical service that meets
their individual needs.
Since 2007, Park Hill Hospital has had formal agreements with the Doncaster &
Bassetlaw Hospitals NHS Foundation Trust to provide elective orthopaedic
procedures, which now also includes general surgery procedures.
Quality Accounts 2013/14
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Appendix 1
Services covered by this quality account
Services Provided
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Dermatology
Ear Nose and Throat (ENT)
General surgery
Gynaecological
Neurology
Ophthalmic
Orthopaedic
Pain management
Physiotherapy
Rheumatology
Sports medicine
Urology
Day and Inpatient Surgery
Dermatology
Cosmetic/plastic
Ear, Nose and Throat (ENT)
Gastrointestinal, General surgery
Gynaecological
Neurology
Ophthalmic
Oral maxillofacial
Orthopaedic
Pain management
Physiotherapy
Rheumatology
Sports medicine
Urology
Vascular
Peoples Needs Met for:
All adults 18 yrs and over
Children 3 yrs and over - outpatients only
All adults 18 yrs and over excluding:
Patients with blood disorders (haemophilia,
sickle cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA
screen are deferred until negative
Patients who are likely to need ventilatory
support post operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission
to ITU post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or
dyspnoea at rest)
Poorly controlled asthma (needing oral steroids
or has had frequent hospital admissions within
last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal
activity e.g. 1 flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we
will only exclude patients if we are unable to provide an
appropriate and safe clinical environment.
Diagnostic
and
screening
Phlebotomy, Urinary Screening and Specimen collection.
Services subcontracted to the Trust hospital include
medical imaging, MRI/CT, ultrasound and
echocardiography.
Quality Accounts 2013/14
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Appendix 2
Clinical Audit Programme 2013/14
Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
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Park Hill 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.
01302 553321
For further information please contact:
01302 730300
www.parkhillhospital.co.uk
Quality Accounts 2013/14
Page 47 of 47