Pinehill Hospital
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
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
Welcome to Ramsay Health Care UK
Pinehill 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, under the lead of North East Essex CCG.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring
that high quality patient care is our number one goal. This relies not only on
excellent medical and clinical leadership in our hospitals but also upon an
organisation wide commitment to drive year on year improvement in patient
satisfaction and clinical outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is not
about reliance on one person or a small group of people to be responsible and
accountable for our performance. It is essential that we establish an
organisational culture that puts the patient at the centre of everything we do and
as a long standing and major provider of healthcare services across the world,
Ramsay has a very strong track record as a safe and responsible healthcare
provider and we are proud to share our results.
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every year
we set our targets higher, working on every aspect of our service to bring a
continuing stream of improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2013/14
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Introduction to our Quality Account
This Quality Account is Pinehill’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
Paul Tempest, General Manager
Pinehill Hospital
Signature
Ramsay Health Care UK is committed to establishing an organizational culture
that puts the patient at the centre of everything we do. As the General Manager, I
am passionate about ensuring that high quality patient care is at the centre of
what we do and how we operate our hospital. This relies not only on excellent
medical and clinical leadership but also on our overall continuing commitment to
drive year on year improvement in clinical outcomes.
The Pinehill Hospital Vision Statement is to be a leading provider of health care
services by delivering high quality outcomes for patients and ensuring long term
profitability. This vision is reflected throughout the Quality Report in that the
hospital will constantly strive to improve the quality and suitability of its services to
patients by ensuring there are adequate core policies and skills, effective
feedback mechanisms on the quality and efficacy of its activities and processes in
place to effect improvement at all levels of the organisation.
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The Quality Reports are reviewed regularly by the Hospital Senior Management
Team to ensure that lessons are learnt, and actions implemented to effect service
improvements.
Pinehill Hospital has a tradition of working closely with Consultants and patients
to ensure the best quality healthcare is consistently being delivered.
During this last year, we have implemented and developed Patient Led
Assessments of the Care Environment (PLACE), a national initiative, and have
involved past patients with this. Their input and support has been greatly
appreciated.
Similarly we have worked closely with the Gastroenterologists in preparing the
Hospital and team for the Joint Advisory Group (JAG) accreditation, with the
inspection planned for early April 2014.
Our hospital staff are fully trained in the latest procedures and thus maintain all
areas to the highest standards. Working within the Department of Health
guidelines we focus on patient safety and cleanliness to minimize infection. Any
patient who wants to satisfy themselves on the quality of the hospital and its’
Consultants can be reassured by the Care Quality Commission (CQC) Audits
undertaken by the Department of Health which support the hospital’s excellent
reputation. As General Manager of Pinehill Hospital, I take great pride in the
service we offer our patients and relatives; this is only achieved through a
cohesive team effort and approach. The hospital also undertakes Patient Led
Assessment of the Care Environment (PLACE) on a yearly basis.
I fully endorse this Quality Account and the information it provides for patients and
commissioners to confirm to them that we meet consistently high standards
across the range of activities we provide. As a long standing and major provider
for healthcare services across the world, Ramsay has a very strong record as a
safe and responsible healthcare provider and we are proud to share our results.
Our emphasis is to ensure patients receive safe and effective care, that they feel
valued and respected in decisions about their care ensuring they are fully
informed about their treatment at each step of their pathway. We especially value
patient’s feedback about their stay, treatment and clinical outcome.
In preparing this report, the hospital has taken into account the views of a wide
range of stakeholders in the hospital’s activities, including staff, consultants and
the Ramsay organisation, but most importantly the views of patients and their
families which have been sought through questionnaire survey, comments sheets
and focus groups. Furthermore, you are invited to feedback on this document by
sending any comments in writing to me at the 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.
Paul Tempest
General Manager
Pinehill Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Sanjay Gupta
MAC Chair
Mr Hilary Thompson
Clinical Governance Committee Chair
Richard Parsons
Regional Director
Commissioner/PCT and other external bodies
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Welcome to Pinehill hospital
Pinehill hospital


Pinehill Hospital is a beautifully converted former stately home and POW
hospital.
It is set in excellently maintained gardens on the edge of a residential
housing estate. Access to Pinehill Hospital is via Hitchin and is well
signposted.

Pinehill has 23 in-patient bedrooms, 2 of which are twin-bedded and all
rooms have en-suite facilities to ensure privacy and dignity. Additionally
there is a detached Day Care Unit with 7 patient bays and 8 further
bedrooms. The Hospital has 3 main theatres and a minor
theatre/endoscopy suite.

The out-patient department has 10 consulting rooms with 2 treatment
rooms, a physiotherapy department with gym, an imaging department with
x-ray, ultrasound and mammography. A Mobile CT/MRI unit is at the
Hospital site 2 or 3 times per week according to patient need.

All 155 Consultants are subject to strict vetting procedures to ensure only
those with the appropriate experience and qualifications are granted
Practising Privileges and offer treatment at Pinehill Hospital.

The staff at Pinehill are professional and friendly, delivering high levels of
customer service. Together we provide fast, convenient and high quality
treatment for patients of all ages, whether medically insured, self funded or
via the NHS. Children (those under the age of 19 years) are non-NHS
funded, with in-patient admissions being for those over 3 years of age only.
Our NHS funded patients are predominantly via the East & North Herts
NHS CCG, but also from Luton and Bedfordshire CCGs.

Patients can self refer for Cosmetic Surgery consultation, and for some
physiotherapy services.

Medical and surgical procedures are provided for most specialties,
including gynaecology, urology, orthopaedic, ophthalmology, dental,
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dermatology and physiotherapy. We also provide diagnostic services such
as radiology and some quality assured pathology on site.

Last year (April 2013 – March 2014), Pinehill admitted a total of 7290
patients of which 4064 (55%) were NHS funded.

A well qualified and experienced Resident Medical officer is on site 24
hours/day to provide high quality medical care to patients under the
direction of their Consultant.

We are very progressive in ensuring that we follow Best Practice wherever
possible, constantly developing our staff in order that services are
consistently reviewed and further improved according to national
guidelines. This also results in high retention and low turnover due to
general satisfaction and challenge for all staff.

We have an active recruitment programme, ensuring that replacement staff
are recruited into new roles and existing vacancies without unnecessary
delay, thus resulting in continuity within the Hospital team, both clinically
and otherwise. We can report repeated success in recruiting staff with
expired clinical qualifications and supporting them through training to
return them to the professional workforce, and indeed we employed two
theatre staff with expired qualifications and now they are again fully
fledged Operating Department Practitioners (ODP).

We also now employ newly qualified staff and ensure a good thorough
induction, not only into Pinehill Hospital and Ramsay Health Care, but also
to the profession to which they now belong.

Whilst there is a national shortage of registered nurses, we are committed
to developing our Health Care Assistants (HCAs) through clinical
competencies to enable them to undertake more nursing duties and
support the registered staff in maintaining clinical standards throughout the
patient journey. We are proud to say that the majority of our HCAs have
already completed the Immediate Life Support (ILS) course. Our HCAs
also fulfill ‘assistant’ roles within physiotherapy, supporting the qualified
physiotherapists in the care of patients with ongoing support and exercise.
We will shortly be supporting a theatre HCA whilst she completes the NVQ
level 4 training within her interest of endoscopy enabling her to fulfil a
valuable role in the care of these patients with confidence and
competence.
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
Permanent hospital staff include Registered Nurses, Health Care
Assistants, Operating Department Practitioners, Physiotherapists,
Pharmacists, Radiographers, administrative staff, caterers, housekeepers,
porters and an engineer. A breakdown of permanent and bank staff
follows:
Contract
Bank
Clinical
64
58
16
23
HCAs
17
14
Admin
35
21
Total
132
116
Support services

Direct access referrals to the Hospital services are accepted from GPs into
Endoscopy and Ophthalmology.

Pinehill is part of the Eastern Region of Ramsay Health Care and enjoy the
services of a GP Liaison Officer, ensuring that the GPs are always in touch
with us and informed as to the services that we offer and are developing at
any time. We have GP education events planned every 6 weeks or so,
including training, networking, certificates and CPD points as well as a hot
meal! This year’s programme includes topics around urology,
opthalmology, ENT, joint injections, to name but a few. These are always
well attended.

Our resuscitation officer trains the GP surgery staff in the skills of Basic
Life Support and our Infection Prevention and Control (IPC) team have
presented topical information at similar sessions.

Pinehill Hospital works closely with local Clinical Commissioning Groups in
Hertfordshire and the surrounding area to support commissioning of
healthcare services for the local population. We have close links with the
East and North Herts NHS Trust, including histopathology, blood
transfusion services and emergency transfer provision.
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
Pinehill has a very high spirit of community within our team and participate
in community activities such as The Race for Life and supporting the local
Hospice in their fund raising campaigns.

Pinehill also supports the Women for Women charity which raises funds to
treat life-threatening conditions affecting women and babies, on a biannual basis and recently raised over £4000, to be repeated again in 2014,
hopefully with a similar result.
A Macmillan coffee morning was staged, raising over £270 and 4 male
members of staff declined to shave off facial hair during November using
the excuse of ‘Movember’ charity, raising £304.

Pinehill has developed close relationships with the local schools, and have
some of their art work displayed through the hospital. We also provide
educational visits for the students and support local junior football teams.

Pinehill also provides swift radiological diagnostic services to team players
of Stevenage Football Club.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2014/15
On an annual cycle, Pinehill Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the 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)
Clinical priorities for 2012/13 included patient consent and issues around
administration of medication.
Patient consent
Audits around consent consistently scored toward the lower end of
‘satisfactory’ with a review evidencing that the clinical staff were not
completing stage 2 of the patient consent immediately prior to the patient
transfer to the operating theatre.
Therefore extra information and training was provided to this group of staff
explaining the requirements for this, with particular attention to the
complete process of consent. Higher scores are now being achieved
throughout all specialties, commonly reaching the high 90s as a
percentage and patients are assured that all checks are in place to
maintain their safety at all times.
Administration of medication
Medication error reports were presented to the local Clinical Governance
Committee, where registered staff were administering meds against
prescriptions displaying various errors, including lack of prescriber
signature, incorrect dose or time for administration etc. These staff
members were potentially at risk of facing disciplinary action and involved
a number of staff. On further review of these incidents, prescriber error
was noted and so a collaborative approach was required, involving
prescribers, administrators, the pharmacist and the CG committee.
The nursing staff received further training updates on administering
medication safely and accurately, whilst also being supported to challenge
prescribers where inaccuracies were noted.
The SMT have written to ‘repeat offending’ prescribers in an effort to raise
awareness throughout the hospital and protect patients and administering
staff.
Although there has been a vast improvement, this needs to remain on the
list for the coming year.
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2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient consent process
We continue with the work around patient consent to ensure continuous
improvement and maintenance of high standards of care and patient safety,
aiming to achieve an audit score of > 96%.
We also continue to monitor the prescribing efficiencies and accuracies as
patient safety is paramount to us at Pinehill Hospital, thereby reducing the
number of medication errors to within single figures.
Infection prevention and control
In addition to this we will concentrate on the patient perception of hand
hygiene by Pinehill staff. The patient surveys continually indicate that they do
not observe staff, particularly nursing staff, cleanse their hands as frequently
as they would like. To this end we have installed hand cleansing gels within
every patient bedroom and other public areas within the Hospital, with staff
being reminded not only to thoroughly wash their hands, but to bring this into
sight of their patients to re-enforce the infection prevention and control
message to all. The success of this will be demonstrated in the patient
satisfaction scores.
We will continue with the project within the ward areas to complete both the
clean and dirty utility areas, facilitating the separation of clean and dirty
consumables and nursing practises.
Conversion of the first floor dirty utility area is almost complete and then we
commence work on the resulting enlarged clean utility area to provide clean
and less distractional space for nursing staff in the preparation of medicines,
facilitating safer practice and effects for our patients.
Once the first floor is complete, we will move up to the lesser used second
floor, providing similar workspaces as on the first floor, thus improving staff
efficiencies and therefore continuity of care for our patients.
Local Clinical Governance Committee
There has been inconsistent input from our Consultant group into this
committee and so one of our tasks this year is to increase attendance at
meetings and innovations into the clinical effectiveness at Pinehill. This will of
course guarantee the highest possible standards if care delivery to our
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patients and increase their confidence in to the service delivery. All practices
will be closely monitored, with research being paramount into the acceptance
of new practices and ongoing audits ensuring that standards are met.
The audits are reported both through the Corporate audit programme, but
also directly to the local clinical governance committee for further review and
action. Action plans will be timely, achievable and realistic and reviewed at
regular intervals to ensure compliance.
Unfortunately we have experienced a substantial turnover within the role of
Ward Manger resulting in severe lack of leadership in the ward team. The
successful and effective recruitment of a Ward Manager will provide the
required leadership and security within the ward team, reducing adverse
incidents and complaints.
This recruitment will also improve completion of appraisals and personal
development plans for team members.
Such continuity will also have significant positive outcomes within other areas,
including:
Levels of achieved attendance at Mandatory Training
Friends and Family development for in-patients
Consent Audits
And other developmental areas to further safeguard patients and staff,
improving standards and staff morale.
2.2 Mandatory Statements
2.2.1 Review of Services
During 2013/14 Pinehill Hospital provided and/or subcontracted 23 NHS services.
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Pinehill Hospital has reviewed all the data available to them on the quality of care
in a number of these NHS services.
The income generated by the NHS services reviewed in 1 April 2013 to 31st
March 14 represents XX per cent of the total income generated from the provision
of NHS services by Pinehill Hospital hospital/centre for 1 April 2013 to 31st March
14.
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospitals
senior managers together with Regional and Corporate Senior Managers and
Directors. The balanced scorecard approach has been an extremely successful
tool in helping us benchmark against other hospitals and identifying key areas for
improvement.
In the period for 2013/14, the indicators on the scorecard for the end of year
performance which affect patient safety and quality were:
Human Resources
Staff Cost % Net Revenue
HCA Hours as % of Total Nursing
Agency Cost as % of Total Staff Cost
Ward Hours PPD = 5.2
% Staff Turnover = 13.7
% Sickness = 4.61
% Lost Time = 15.2
Appraisal = 62%
Mandatory Training 92%
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Staff Satisfaction Score = 4.66 overall
Number of Significant Staff Injuries = 5
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score = 92.5%
Significant Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score = 92%
2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014 Pinehill Hospital participated in 92%
national clinical audits and 100% 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 Pinehill
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.
Pinehill Hospital is registered for 42 beds with no formal High Dependency Care
or Intensive Care units and therefore has been illegible to submit data for the
majority of national audits due to low patient numbers.
However we have submitted data for the National Joint Registry (NJR) and the
elective surgery (National PROMs Programme as below:
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Name of audit / Clinical Outcome
Review Programme
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
% cases
submitted
87
91
The Pinehill Hospital CGC have reviewed the national audits list for next year and
will be potentially participating (patient incident numbers permitting) for those on
the following list:
Name of audit / Clinical Outcome
Review Programme
Emergency use of oxygen
Medical and surgical clinical outcome
review programme: National
confidential enquiry into patient
outcome and death
National Joint Registry (NJR)
Severe sepsis & septic shock
National Comparative Audit of Blood
Transfusion programme
Care of dying in hospital (NCDAH)
Diabetes (Adult) ND(A), includes
National Diabetes Inpatient Audit
(NADIA)
Inflammatory bowel disease (IBD)*
Pain database
Elective surgery (National PROMs
Programme)
National Health Promotion in Hospitals
Audit
Pain management
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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 Pinehill Hospital intends to
take the following actions to improve the quality of healthcare provided. The
clinical audit schedule can be found in Appendix 2.
Consent audit: low scores have instigated a team effort in improving compliance
with the patient receiving their own copy of the completed form and with the
production of colour patient information leaflets.
The anaesthetic audit results have lead to many discussions at the local CGC
where it is argued that some of the required patient data is recorded already, and
so the anaesthetist is simply repeating this data onto the anaesthetic form.
The Lead CCG required monthly hand hygiene audits, which have constantly
produced scores between 95 and 100%.
2.2.3 Participation in Research
There were no patients recruited during 2012/13 to participate in research
approved by a research ethics committee.
During this period Pinehill Hospital have provided the service of Platelet Rich
Plasma to patients with conditions such as tendonitis. This has necessitated the
production of new patient information leaflets and the purchase of a centrifuge to
be able to produce required concentrate of Platelets to the treatment area by
injection under ultrasound control.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Pinehill Hospital’s income from 1 April 2013 to 31st March 2014
was conditional on achieving quality improvement and innovation goals agreed
with the Lead CCG, North East Essex 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.
2.2.5 Statements from the Care Quality Commission (CQC)
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Pinehill Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions, following
an unannounced inspection on 13th December 2013.
Pinehill 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
Statement on relevance of Data Quality and your actions to improve your
Data Quality
Data quality is critical to the work of the hospital, providing high quality data for
clinical review, service improvement, patient and client satisfaction and accurate
charging and billing.
This hospital is proud to report that it was shortlisted for a national award by
CHKs for accurate and complete data quality, reinforcing the extremely good
work done by the hospital staff in this area.
The hospital will continue to review the quality of data in all areas and will aim to
improve data accuracy and completeness where issues are identified.

Continue monthly review of SUS and billing data quality to CCGs

Monthly data checking of clinical coding through internal and external
audits

Quality patient and staff satisfaction surveys

Regular clinical audits
NHS Number and General Medical Practice Code Validity
Pinehill 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).
The General Medical Practice Code:

100% for admitted patient care;
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

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
for 2013/14 was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Pinehill Hospital hospital/centre was not subject to the Payment by Results
clinical coding audit during 2013/14 by the Audit Commission.
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Matron, (Mary Barrett)
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.
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The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
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
Quality Accounts 2013/14
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Ramsay Health Care Clinical Governance Framework
National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
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3.1 The Core Quality Account Indicators
1. Mortality
Period
Best
Worst
Average
Pinehill
2012/13
RKE
0.65
RXL
1.17
Eng
1
NVC15
0
2013/14
RKE
0.63
RBT
1.15
Eng
1
NVC15
0
2. Expected deaths
Period
Apr12 Mar13
Jul12 - Jun13
Best
Worst
Average
Pinehill
RBA
0.1
RWH
44.0
Eng
20.4
NVC15
0.0
RBA
0.0
RWH
44.1
Eng
20.2
NVC15
66.6
Prescribed Information
The summary hospital-level mortality indicator
figures are not available for independent
sector hospitals,
Related NHS Outcomes
Framework Domain
1: Preventing People from dying
prematurely
2: Enhancing quality of life for
people with long-term conditions
Pinehill Hospital considers that this data is as described for the following reasons:
Pinehill Hospital has very few patient deaths: all admitted NHS funded patients
are for elective surgery and are pre-screened prior to admission
3. Readmissions
Period
Best
Worst
Average
Pinehill
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
NVC15
7.97
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
NVC15
6.01
Quality Accounts 2013/14
Page 27 of 40
The data made available to Ramsay Health
Care by the Health and Social Care
Information Centre with regard to the
percentage of patients aged(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital within 28 days of
being discharged during the reporting period.
3: Helping people to recover
from episodes of ill health or
following injury
Pinehill Hospital considers that this data is as described for the following reasons:
All readmitted patients that we are aware of are reported accordingly onto our
electronic reporting tool.
Pinehill Hospital intends to improve this data collection through close liaison with
the East & North Herts Clinical Commissioning Group in conjunction with the local
NHS Trusts and GP surgeries.
4. Responsiveness: To Personal Needs
Period
Best
Worst
Average
Pinehill
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
NVC15
91.3
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
NVC15
90.4
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.
Pinehill Hospital considers that this data is as described for the following reasons:
This data is taken from the CQC Inpatient Survey, part 4b, on a scale of 1 – 10.
Quality Accounts 2013/14
Page 28 of 40
5. Treating and caring for people in a safe environment (VTE assessment)
Period
Best
Worst
Average
Pinehill
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
NVC15
96.5%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
NVC15
98.7%
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
Quality Accounts 2013/14
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Pinehill Hospital considers that this data is as described for the following
reasons:
This data is collected at source and stored within the Patient Administration
System.
6. Treating and caring for people in a safe environment (C Difficile infection)
Period
Best
Worst
Average
Pinehill
2012/13
Several
0
RNA
58.2
Eng
22.2
NVC15
0.0
2013/14
Several
0
RVW
30.8
Eng
17.3
NVC15
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
Pinehill Hospital considers that this data is as described due to efficient reporting
systems and infections reported to the Infection Prevention and Control team.
The use of single patient bedrooms is a great advantage within the Independent
Health Sector for control of all infections.
7. Treating and caring for people in a safe environment (incident rate)
Period
Best
Worst
Average
Pinehill
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
NVC15
3.86
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
NVC15
4.72
8. Treating and caring for people in a safe environment (serious untoward
incidents)
Period
Best
Worst
Average
Pinehill
Quality Accounts 2013/14
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Jul - Sep 12
Oct11 Sep12
NA
NA
NA
NA
NA
Eng
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
11,563
NVC15
0.0%
NVC15
1.6%
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Pinehill Hospital considers that this data is as described for the following
reasons:
All such data is entered onto the electronic risk management system. There may
be 1 or more incidents during a single admission and so these figures may not
accurately reflect on the patient episodes.
This figure represents the Hospital and grounds only.
9. Ensuring that people have a positive experience of care
Period
Best
Worst
Average
Pinehill
Jan-14
Several
100
RPA02
27
Eng
73
NVC15
95
Feb-14
Several
100
RPA02
18
Eng
73
NVC15
95
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
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Pinehill Hospital considers that this data is as described as patients complete
this survey of their own free will and it is reflective of other anonymous patient
satisfaction survey material.
Staff have the opportunity to complete ‘on-line’ satisfaction surveys, but can also
have a hard copy if preferred.
Pinehill Hospital intends to approach more patients with this survey, to include
visitors to the out-patient department.
Further encouragement to staff to complete the appropriate surveys.
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.
All aspects of patient safety and clinical quality are discussed at the bi-monthly
local CGC meetings.
The committee membership includes consultant surgeons, anaesthetist and
hospital team members such as the hospital Infection Prevention & Control Lead,
the hospital blood transfusion nurse, theatre manager and Matron.
Extra guest presenters are invited appropriately. A full report is prepared for the
Medical Advisory Committee which includes recommendations as to agreed new
procedures and also actions such as restrictions to medical practice.
Major issues are escalated to the Corporate CGC with advice/support being
available at any time on request.
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
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3.2.1 Infection prevention and control
Pinehill hospital has a very low rate of hospital acquired infection and has
had no reported MRSA Bacteraemia or Clostridium Difficile in the past 3
years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:

A Corporate level annual audit programme, with an IPC focus every
month.

A corporate level IPC committee. A summary of the minutes are circulated
through the company to local units and discussed at various local
committee groups.

The infection prevention and control sessions within induction and
mandatory training sessions are delivered by the lead nurse who maintains
best practice by interacting with other Ramsay sites, but also by attending
the IPC committee meeting held at the local NHS Trust.

Matron is in contact with both the local Trust and also with various GP
surgeries to ensure that appropriate data is shared with us.

Public awareness ‘stands’ in the main reception area of the hospital.

Bi-monthly committee meetings with the Chair being a fully authenticated
microbiologist.
Quality Accounts 2013/14
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
The surveillance will be increased to include major gynaecology and spinal
procedures in the following year as part of the CQUIN improvement plan.
Local infection rates as a % of admissions for the last 3 years:
As can be seen in the above graph our infection control rate has increased over
the last year, but is still at a very low rate at 0.7% of all admissions.
This is due to a number of reasons:
1. More active reporting using the electronic reporting system and the rollout
of this to all staff members
2. Better and more efficient data collection by the IPC team and links with the
local GP surgeries
3. An additional IPC nurse to investigate all infection prevention and control
specimens, together with all identified trends and analysis of these.
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 Pinehill 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.
Quality Accounts 2013/14
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Pinehill Hospital scored 71% overall:
Cleanliness 82%
Food & Hydration 81%
Privacy, dignity & wellbeing 78%
Condition, appearance & maintenance 78%
Although Pinehill scored an average par with the majority of healthcare providers,
we were disappointed with the results and have worked hard in all areas to
improve for the future. This will hopefully be reflected in the scores from the May
2014 audit. This is the first time that this type of audit has been undertaken here
and has provided valuable insight.
Areas have been refurbished, a new chef has been employed, extra attention is
given to patient dignity and privacy at all time in all areas of the hospital, and the
hospital is a much brighter and well presented environment as a result.
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.
Local safety initiatives include:
 a local bi-monthly committee meeting which includes a review of the
corporate level committee meeting notes
 a quality and patient safety walkabout by the local CCG which includes a
section: Is the area clean and tidy?
 collection and submission of surgical site infection data
 monthly hand hygiene audits of staff throughout the hospital
Quality Accounts 2013/14
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



free flu vaccines for staff
antibiotic audit for surgical patients
norovirus posters are in place on the back of public toilet doors
staff training in the use of the new safety needles.
3.3 Clinical effectiveness
Pinehill Hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
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.
Quality Accounts 2013/14
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As can be seen in the above graph our returns to theatre rate has decreased over
the last year resulting from effective and early use of the Modified Early Warning
Scores, both within the theatre recovery area and in the ward areas. We have
also recruited into existing vacancies and provided our Health Care Assistants
with further training and insight into recognising potential problems at an early
stage. The theatre team are encouraged to speak up should they have concern
over a procedure or surgeon and are valuable members of the team.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also fedback 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 fedback 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
Quality Accounts 2013/14
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




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.
As can be seen in the above graph our Patient Satisfaction rate has remained
almost static over the last year.
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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Pinehill 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:
01462 422 822
www.pinehillhospital.co.uk
Quality Accounts 2013/14
Page 40 of 40