Renacres Hospital
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholder’s views on Renacres Hospital
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
Patient Feedback
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Renacres 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 Renacres Hospital 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
“Renacres Hospital is committed to being a leading provider of outpatient,
diagnostic, day case and in-patient services by delivering high quality outcomes
and an excellent patient experience.
Renacres Hospital has become an integral part of NHS healthcare provision in
Lancashire, particularly since its participation in delivering the E05 Cumbria and
Lancashire Phase II Elective Surgery Agreement, which was in place 2007-2012.
Today the hospital continues to deliver high quality care under contract with the
local Clinical Commissioning Groups and a key reason for the hospital’s
continued role in local NHS healthcare provision is the high standard of care
provided.
Ramsay Health Care UK has an organisational culture that puts the patient at the
centre of everything we do. As General Manager of Renacres Hospital, I am
passionate about ensuring that high quality patient care is our number one
priority. This relies not only on excellent medical and clinical delivery but also
upon continued commitment to driving improvement in clinical outcomes. Ramsay
Health Care UK has a structured clinical governance framework that enables
continual review of performance. This allows us to drive improvements for the
benefit of all patients.”
Margaret-Ann Worrell
General Manager, Renacres 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.
Margaret-Ann Worrell
General Manager, Renacres Hospital
This report has been reviewed and approved by:
Chorley and South Ribble Clinical Commissioning Group
Simon Jones, Consultant Surgeon and Chair Medical Advisory Committee,
Renacres Hospital
Stefan Andrejczuk, Regional Director
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Welcome to Renacres Hospital
Renacres Hospital is located near Southport, close to the M58 and M6. The
hospital opened in 1987 and currently has twenty three single rooms all with ensuite facilities and two three chaired rooms for ambulatory patients.
Renacres Hospital provides fast, convenient, effective and high quality treatment
for patients of all ages (excluding children) whether medically insured, self
funding or from the NHS. The Hospital offers a comprehensive range of
treatments and services including ENT procedures, Maxillofacial and Dental
surgery, Plastic surgery, Gynaecology, General Surgery, Orthopaedics and
Urological procedures.
Diagnostic facilities include contrast studies, barium studies, ultrasound,
mammography, MRI and CT, in addition to general radiology.
All of the Hospital’s consultants are highly experienced and have patient care and
comfort as their highest priority. All patients have the reassurance that a resident
doctor is available 24 hours/day.
Our physiotherapy clinic is staffed with chartered, HPC registered
physiotherapists.
Renacres Hospital has two out-patient outreach services based at The Village
Surgery, Formby and Birleywood Surgery, Skelmersdale.
Renacres Hospital is part of the Cheshire and Mersey Critical Care Network and
has a Service Level Agreement in place for emergency transfer of critically ill
patients.
Renacres Hospital supports local charities and other groups. Last year we
supported Queenscourt Hospice.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Renacres 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 Hospital’s Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
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Priorities for improvement
2.1.1 A review of clinical priorities 2013/14 (looking back)
PLACE – The annual PLACE audit is a patient led audit with an assessment
team that consists of 50% patients.
The audit includes all internal and external areas of the hospital only excluding
operating theatres. The audit is divided by each department of the hospital and
assesses the standard of cleanliness and general upkeep of the building and
grounds. It will also evaluate the standard of the food being served to patients,
ensuring that all dietary requirements are met. The scoring system employs a
system whereby areas are given a ‘Pass’, ‘Fail’ or ‘Qualified Pass’.
Renacres Hospital PLACE audit took place on 14th June 2013 and the following is
an overview of the scores achieved:
Cleanliness – 96.15%
Food – 95.51%
Privacy – 96.43%
Condition – 94%
Public bodies including; The Care Quality Commission, The NHS Commissioning
Board and The Department of Health use information from the PLACE
assessments to ensure that all patients are given a high quality service.
Clinical Documentation Audits - Remained a priority in all areas with a
corporate Ramsay focus set for 2013/14 on theatre safety checks and
Physiotherapy documentation checks. The team achieved full completion of the
Ramsay Corporate Audit Programme in the relevant timeframes.
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Local CQUINS
Smoking Cessation - The hospital identified and recorded smoking status of
all admitted patients and recommended appropriate intervention. The hospital
achieved a compliance rate of 100% for 2013/14.
Alcohol Awareness – The hospital identified and recorded alcohol use of all
admitted patients and recommended appropriate intervention. The hospital
achieved a compliance rate of 100% for 2013/14.
National CQUINS
Friends and Family Test – The hospital undertook Friends & Family testing
with both inpatient and daycase patients in the period, achieving a 50%
response rate and a 99% rate for ‘Extremely Likely to recommend’. The
hospital undertook Friends & Family testing with staff in the period, achieving
a 68% response rate and a 97% rate for ‘Extremely Likely to recommend’.
VTE Risk Assessment – The hospital was set a compliance target of 97%,
for the period compared to the national target of 95%, and continuously
achieved this reaching 99.4% compliance in April 2014.
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2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient Safety
Safety Thermometer. The Safety Thermometer focuses on the reduction of
patient harm. The power of the NHS Safety Thermometer lies in allowing frontline
teams to measure how safe their services are and to deliver improvement locally.
The data can also be aggregated to measure improvement at a regional and
national level.
The Safety Thermometer is a national CQUIN indicator and in 2013/14 Renacres
Hospital achieved its CQUIN target.
In the forthcoming year the CQUIN will focus on reduction in the prevalence of
pressure ulcers.
Surgical Safety Checklist – ‘Never Events’ are serious, largely preventable
patient safety incidents that should not occur if the available preventative
measures have been implemented as standard practice. Monthly audits will
continue to be undertaken with an expectation of 100% compliance. Where this is
not achieved actions plans will be developed and responsibilities communicated
with the teams. Briefing and debriefing sessions after all operating sessions
continue and give opportunity for shared learning, recommendations for future
practice and aim to encourage autonomy for all members of the team.
Compliance will be monitored by regular audit and reviewed by the hospital’s
Clinical Governance and Medical Advisory Committees.
VTE Assessment - A VTE risk assessment is completed for patients according to
CM 001 VTE policy and requires consultants to review and to complete prior to
procedure. This remains a focus at Renacres Hospital with quarterly audits
completed to maintain standards. Results are reviewed and actions determined at
the hospital’s Clinical Governance and Medical Advisory Committees.
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Clinical Effectiveness
Meeting Endoscopy Standards. Renacres Hospital is to undergo the JAG
accreditation visit in July 2014. Therefore a key priority for the hospital is
ensuring that BSG and GRS standards are fully met.
Patient Experience
Friends and Family Test. The Friends and Family Test aims to improve the
experience of patients in line with Domain 4 of the NHS Outcomes Framework.
The Friends and Family Test will provide timely, granular feedback from patients
about their experience. In the first six months of use, the Friends and Family test
gathered almost one million responses; by contrast, in the 2012 inpatient survey,
64,500 patients were asked for feedback. Commissioners should be assured that
NHS providers have plans in place to reduce the proportion of people reporting a
poor experience of care in line with the locally set level of ambition.
In addition to the Friends and Family Test of previous years covering in-patient
and day case patients, the test has been extended in 2014/15 to include outpatients.
Patient Satisfaction Survey – We will continue to encourage patients to provide
feedback using our web based satisfaction survey. ‘Hot alerts’ received following
completion of the survey will be reviewed by the General Manger and Clinical
Lead and action taken where there are areas identified for improvement. All
comments positive and negative are shared with the whole team along with a
monthly patient satisfaction dashboard. Compliments and complaints are
reviewed at the hospital’s Clinical Governance and Medical Advisory Committees
and lessons shared with the nursing teams. We will continue to monitor posts on
NHS choices and remain commited to retaining our five star recommendation. We
have added to current patient feedback mechanisms by introducing a patient
focus group and including patients in hospital PLACE audits.
Advancing Quality – this initiative is aimed at improving the quality of care and
patient experience. It is a local CQUIN where Renacres Hospital submits data
regarding DVT and antibiotic prophylaxis. Compliance with completion of data is
expected at 95% and at 80% completion via external audit.
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Equality Delivery System – Renacres Hospital will be one of the first
private hospitals to work on NHS England’s EDS2 initiative to ensure that
the services we provide for patients and that the working environment we
provide to staff is free of discrimination, in accordance with the nine
protected characteristics under the Equality Act 2010; age, disability,
gender reassignment, marriage and civil partnership, pregnancy and
maternity, race, religion and belief, gender and sexual orientation.
Patient Reported Outcome Measures Studies (PROMS) –We will continue to
monitor patient response rates as part of a local CQUIN indicator with a
graduated quarterly target to achieve greater than 80% compliance by quarter
four of 2014/15. The consultant surgeons will ensure patients are fully informed
and invited to take part in the survey by completing a questionnaire prior to their
surgery.
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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 Renacres Hospital provided NHS services across eight surgical
specialties.
Renacres Hospital has reviewed all the data available to them on the quality of
care in all of these NHS services.
The income generated by the NHS services reviewed in 1st April 2013 to 31st
March 2014 represents 100% per cent of the total income generated from the
provision of NHS services by Renacres Hospital for 1st April 2013 to 31st March
2014.
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospitals
senior managers together with Regional and Corporate Senior Managers and
Directors. The balanced scorecard approach has been an extremely successful
tool in helping us benchmark against other hospitals and identifying key areas for
improvement.
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In the period for 2013/14, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
Staff Cost % Net Revenue - 27.3%
HCA Hours as % of Total Nursing – 21%
Ward Hours PPD - 4.8
% Staff Turnover – 9%
% Sickness – 3.7%
% Lost Time – 20.2%
Appraisal % - 100%
Mandatory Training % - 100%
Staff Satisfaction Score - 41.80
Number of Significant Staff Injuries - 0
Patient
Formal Complaints per 1000 HPD's - 0.19
Patient Satisfaction Score – 96%
Significant Clinical Events per 1000 Admissions - 0.58
Readmission per 1000 Admissions - 1.38
Quality
Workplace Health & Safety Score - 98%
Infection Control Audit Score – 99%
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2.2.2 Participation in clinical audit
During 1 April 2012 to 31st March 2013, the hospital participated in both local and
national audits.
The national clinical audits and national confidential enquiries that Renacres
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.
% cases
submitted
Name of audit / Clinical Outcome
Review Programme
100%
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
Small
volumes
Medical and surgical clinical outcome review programme: National
confidential enquiry into patient outcome and death
0% - no
deaths in
period
The reports of 2 national clinical audits from 1 April 2013 to 31st March 2014
were reviewed by the Clinical Governance Committee and Renacres Hospital had
no actions to take as a result of these audits.
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 Renacres Hospital intends
to take the following actions to improve the quality of healthcare provided:
Nutrition and Hydration Audit. Issue relating to full completion of fluid
balance chart was identified and training arranged accordingly.
Consent Audit. Issue identified that certain consultants were not
completing first stage consent in out-patients. This has been addressed
through the Local Clinical Governance Committee and ratified at the
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Medical Advisory Committee (MAC). The issue continues to be monitored
and individual consultants written to by the MAC Chair.
The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2010/11to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of income from 1 April 2013 to 31st March 2014 was conditional on
achieving quality improvement and innovation goals agreed between Renacres
Hospital and the Clinical Lead of the Lead Commissioner for the CCG, through
the Commissioning for Quality and Innovation payment framework.
2.2.5 Statements from the Care Quality Commission (CQC)
Renacres Hospital is required to register with the Care Quality Commission. The
most recent inspection was carried out on 5th November 2013 was inspected in
the following areas and full compliance was awarded:
Consent to care and treatment
Care and welfare of people who use services
Meeting nutritional needs
Cleanliness and infection control
Safety and suitability of premises
Assessing and monitoring the quality of service provision
Renacres Hospital has not participated in any special reviews or investigations by
the CQC during the reporting period.
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2.2.6 Data Quality
The hospital continues to take the following actions to improve data quality:
Regular training to ensure staff understand importance of accurate data
input and have sufficient technical competence
Employment of clinical coder to improve accuracy of recording
Supporting national projects to ensure data accuracy
NHS Number and General Medical Practice Code Validity
Renacres 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;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall
score for 2013/14 was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Renacres 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 Stakeholder’s views on Renacres Hospital
Chorley and South Ribble Clinical Commissioning Group:
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Part 3: Review of quality performance
2013/2014
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. All
Quality Accounts 2013/14
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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
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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
National Mortality Rates:
Period
Renacres Hospital:
Best
Worst
Average
Period
Renacres
2012/13
RKE
0.65
RXL
1.17
Eng
1
2012/13
NVC16
0
2013/14
RKE
0.63
RBT
1.15
Eng
1
2013/14
NVC16
0
Renacres Hospital considers that this data is as described as there were no
deaths for the above period.
National Expected Deaths:
Period
Best
Renacres Hospital:
Worst
Average
Period
Renacres
2012/13
RBA
0.1
RWH
44.0
Eng
20.4
2012/13
NVC16
0.0
Jul12 - Jun13
RBA
0.0
RWH
44.1
Eng
20.2
2013/14
NVC16
0.0
Renacres Hospital considers that this data is as described as we do not admit
patients for palliative care.
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National PROMs:
Groin Hernia
National PROMS:
Period
Apr12 Mar13
Apr13 Sep13
Renacres Hospital:
Best
Worst
Average
NT415
0.157
NVC27
0.015
Eng
0.085
RTG
0.138
RNA
0.019
Eng
0.086
Period
Apr12 Mar13
Apr13 Sep13
Renacres
NVC16
*
NVC16
*
Renacres Hospital considers that this data is as described.
Renacres Hospital has taken action to improve the returns rate of PROMs
questionnaires and so the quality of its services, by actively encouraging patient
participation.
Hip Replacement
National PROMS:
Period
Apr12 Mar13
Apr13 Sep13
Renacres Hospital:
Best
Worst
Average
NT209
24.68
RKE
17.21
Eng
21.32
NT318
25.44
RHQ
18.34
Eng
21.61
Period
Apr12 Mar13
Apr13 Sep13
Renacres
NVC16
*
NVC16
*
Renacres Hospital considers that this data is as described.
Renacres Hospital has taken action to improve the returns rate of PROMs questionnaires
and so the quality of its services, by actively encouraging patient participation.
Knee Replacement
National PROMS:
Period
Apr12 Mar13
Apr13 Sep13
Renacres Hospital:
Best
Worst
Average
NT219
20.37
RAP
12.46
Eng
16.01
RDE
20.09
RM1
14.32
Eng
16.74
Period
Apr12 Mar13
Apr13 Sep13
Renacres
NVC16
*
NVC16
*
Renacres Hospital considers that this data is as described.
Quality Accounts 2013/14
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Renacres Hospital has taken action to improve the returns rate of PROMs questionnaires
and so the quality of its services, by actively encouraging patient participation.
Readmissions
National Readmissions:
Period
Renacres Hospital:
Best
Worst
Average
Period
Renacres
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2012/13
NVC16
10.64
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
2013/14
NVC16
3.89
Renacres Hospital considers that this data is as described as we have a low level of
readmissions reported.
Patient Satisfaction
National:
Renacres Hospital:
Period
Best
Worst
Average
Period
Renacres
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC16
93.2
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC16
93.2
Renacres Hospital considers that this data is as described as it corresponds with the
Patient Satisfaction Survey Results.
VTE assessment
National:
Period
Renacres Hospital:
Best
Worst
Average
Period
Renacres
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q3
NVC16
98.9%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
13/14 Q4
NVC16
99.4%
Renacres Hospital considers that this data is as described because it corresponds with
SUS reports.
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C Difficile rate
National:
Renacres Hospital:
Period
Best
Worst
Average
Period
Renacres
2012/13
Several
0
RNA
58.2
Eng
22.2
2012/13
NVC16
0.0
2013/14
Several
0
RVW
30.8
Eng
17.3
2013/14
NVC16
0.0
Renacres Hospital considers that this data is as described as there were no incidence of C
difficile during the period.
Patient Safety
National:
Renacres Hospital:
Period
Best
Worst
Average
Period
Renacres
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
NVC16
3.12
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
2013/14
NVC16
4
Renacres Hospital considers that this data is as described, we have a low level of patient
incidents reported. Renacres Hospital ensures a safe environment is maintained with all
staff undertaking training and competency assessments and a robust audit system. All
incidents and accidents are reviewed at clinical governance, health and safety and medical
advisory committee and action plans developed and lessons learned shared.
SUI’s Severity level 1
National:
Period
Jul - Sep 12
Oct11 Sep12
Renacres Hospital:
Best
Worst
Average
NA
NA
NA
NA
NA
Eng
Period
11,563
Renacres
2012/13
NVC16
0.0%
2013/14
NVC16
1.8%
Renacres Hospital considers that this data is as described, there have been no level 1
severity incidents reported. Renacres Hospital intends to maintain this rate by ensuring an
effective clinical governance framework.
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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.
3.2.1 Infection prevention and control
Renacres 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.
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Infection Rates
Infection Rates
(percentage of Admissiosns)
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Renacres Hospital
As can be seen in the above graph our infection control rate has increased over
the last year due to improved monitoring and reporting. In comparison to the
national average it is lower.
All Staff undergo Infection Control Training at Induction and annually as part of
the Mandatory Training Programme, which includes both practical training and elearning.
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 Renacres 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.
Renacres Hospital PLACE audit took place on 14th June 2013 and the following
is an overview of the scores achieved:
Cleanliness – 96.15%
Food – 95.51%
Privacy – 96.43%
Condition – 94%
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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.
3.3 Clinical effectiveness
Renacres 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.
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Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.2
0.18
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
2011/12
2012/13
2013/14
Renacres 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.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:




Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
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





‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.4.1 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.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
99.1
95.0
2012/13
2013/14
20
0
Renacres Hospital
A change of satisfaction survey in early 2013 means the data is not comparable.
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3.5 Patient Feedback (Received via Friends & Family April 2014 – first 30
reported comments, listed in consecutive order)
"Good quality care and attention"
"Competent and friendly"
"Excellent friendly staff"
"Looked after very well thank you"
"Quickly seen and constant assistance"
"Very good care given throughout"
"Very happy with nursing staff, accommodation, and excellent explanation given about my treatment.
Operation was without incident and I was discharged with further advice"
"Very pleasant with everything"
"Very professional and caring staff"
"Everyone was pleasant and friendly, a good experience"
"Very good care and consideration throughout my treatment"
"All aspects of my treatment were excellent thank you"
"All staff give you time and help keep you calm. Thank you"
"ALL staff were FANTASTIC and made this procedure much more bearable. Thank you"
"All the staff have been very pleasant and caring"
"Attentive friendly staff and spotless surroundings. Thank you"
"Everyone was helpful and friendly and although we waiting quite a while for surgery the staff more
than made up for the wait"
"Everything was explained and I was made to feel comfortable"
"Unbeatable staff and wonderful consultant"
"Excellent and lovely staff"
"Excellent and prompt care. Thank you"
"Excellent care and attention and a friendly atmosphere"
"Excellent care and staff"
"Excellent care and very friendly staff"
"Excellent facilities and can't fault level of care. Many thanks"
"Excellent service, timely and dignified"
"Excellent staff and service"
"Extremely likely Fine with everything- staff friendly and helpful"
"Found the service better than expected. Staff all friendly"
"Clean hospital. Quick to be seen and was kept up to date on what was happening"
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Appendix 1
Services covered by this quality account
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Peoples Needs Met for:
Audiology, Cardiology, Cosmetics,
Cosmetic Dentistry, Dermatology, Ear,
Nose and Throat (ENT), General
Medicine, General surgery,
Gynaecological, Nephrology, Neurology,
Neurosurgery, Oncology, Ophthalmic,
Orthopaedic, Pain Management, Podiatry,
Psychiatry, Psychology, Physiotherapy,
Rheumatology, Speech Therapy, Sports
medicine, Urology, Vascular ,Intermediate
community care beds
All adults 18 yrs and over
Cosmetics, Day and Inpatient Surgery,
Dermatology, Ear, Nose and Throat
(ENT), General surgery, Gynaecological,
Neuro surgery, Ophthalmic, Oral
maxillofacial surgery, Orthopaedic,
Urology, Vascular
All adults 18 yrs and over excluding:
All children 3 yrs and over, outpatients only
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
Family
Planning
Services
Audiology, GI physiology, Imaging
services, Nerve conduction studies,
Mobile MRI and CT, Phlebotomy,
Urodynamics, Urinary Screening and
Specimen collection.
All adults 18 yrs and over
Gynaecology patient pathway, insertion
and removal of inter uterine devices for
medical as well as contraception
purposes
All adults 18 years and over as clinically indicated
All children 3 yrs and over, outpatients only
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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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Renacres 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:
Telephone: 01704 841133
Web: www.renacres-hospital.co.uk
Quality Accounts 2013/14
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