Rivers Hospital
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
4
Introduction to our Quality Account
5
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
6
1.2
Hospital accountability statement
7
1.3
Welcome to the Rivers Hospital
8-9
PART 2
2.1
Priorities for Improvement
10
2.1.1 Review of clinical priorities 2013/14 (looking back)
10
2.1.2 Clinical Priorities for 2014/15 (looking forward)
11-12
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
13
2.2.2 Participation in Clinical Audit
14
2.2.3 Participation in Research
15
2.2.4 Goals agreed with Commissioners
16
2.2.5 Statement from the Care Quality Commission
16
2.2.6 Statement on Data Quality
17
2.2.7 Stakeholders views on 2010/11 Quality Accounts
18
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
20-23
3.2
Patient Safety
24-25
3.3
Clinical Effectiveness
26-27
3.4
Patient Experience
27-29
3.5
Case Study
30
Appendix 1 – Clinical Audits
31
Welcome to Ramsay Health Care UK
Rivers 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 Rivers Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the General Manager
Rivers Hospital has a tradition of working closely with consultants and patients to
ensure the best quality healthcare is consistently being delivered. 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. Care Quality Commission
(CQC) Inspection outcomes reflect the high quality at Rivers and therefore
support its excellent reputation. As General Manager of Rivers 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 Rivers 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 affect improvement at all levels of the organisation.
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 though questionnaire survey, comment sheets
and focus groups. Furthermore, you are invited to feedback on this document by
sending any comments in writing to me at the hospital
Monica Clarke, Interim General Manager
Rivers Hospital
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Quality Accounts 2013/14
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1.3 Welcome to Rivers Hospital
The Rivers is a private hospital set in quiet landscaped grounds in
Sawbridgeworth, Hertfordshire. It is one of the largest hospitals within Ramsay
Health Care UK. It opened in March 1992, and has become popular with patients
from the Hertfordshire and Essex region. It is easily accessible with free car
parking.
The Rivers has 59 in patient bedrooms; all have en-suite bathrooms to ensure
patient comfort and privacy. Additionally there is a dedicated day case suite with
9 bays, and a minor ops theatre. The hospital has four operating theatres, which
are well equipped with the latest surgical technology.
The Outpatient Department has 15 Consulting rooms and 3 private treatment
rooms, with a modern equipped physiotherapy department and gym, a well
equipped imaging department with x-ray, ultrasound, CT & MRI scanning
facilities, Digital Mammography and DEXA scanning (Osteoporosis). Our MRI
scanning facility has been upgraded this year.
All 200 plus Consultants are subject to strict vetting procedures to ensure only
those with the appropriate experience and qualifications are granted Practising
Privileges and hence can offer treatment at Rivers Hospital.
The Staff at the Rivers are professional and friendly, and deliver high levels of
customer service. In 2010 the hospital won the Harlow and District Business
Awards for Customer Care and has also been successful in achieving Top 10
places in the Healthcare 100 Best Employer Awards (IPSOS Mori) over recent
years.
We provide fast, convenient, effective and high quality treatment for patients of all
ages (children over the age of 3 years as inpatients), whether medically insured,
self-pay, or NHS funded.
Patients may self refer for Cosmetic Surgery consultation, and for Physiotherapy
services.
The Rivers offers a range of elective surgical, non-surgical and outpatient
treatments across the following specialities: Allergy Clinic, Bariatrics, Breast /Reconstructive surgery, Cardiology (Cardiothoracic Surgery at Orwell Suite), Colo-rectal surgery, Cosmetic surgery,
Dermatology, Diabetes/Endocrinology, Diagnostic Services, Dietician, Ear, Nose
and Throat, Endoscopy, Fertility services, Gastro-enterology, General Medicine,
General surgery, Gynaecology, Haematology, Health Screening, Laparoscopic
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Surgery, Neurology, Neuro-Radiology, Oncology, Ophthalmology, Oral and
Maxillo-Facial Surgery, Orthopaedic Surgery, Paediatric Services, Pain Medicine,
Pharmacy, Physiotherapy, Plastic Surgery, Private GP & Practice Nurse service,
Psychiatry, Psychotherapy, Rheumatology, Spinal Surgery , Urology including
Brachytherapy, Vascular, Weight loss Clinics, Bariatric Surgery.
The Hospital attracts referrals from sister hospitals within Ramsay Eastern region
as a specialized centre for services such as Brachytherapy (Prostate Cancer),
Chemotherapy
services (Cancer), DEXA scanning (Osteoporosis),
Phototherapy (Skin conditions), and on site CT scanning (Diagnostic Imaging).
The Rivers acts as a satellite for other centres to offer services through a hub &
spoke system. These include Fertility services (Bridge Fertility Centre) and
Cardio-thoracic surgery (Ramsay Orwell Suite).
Last Year the Rivers admitted a total of 13,282 patients.
An experienced Resident Medical Officer is on site 24 hours/day to provide high
quality medical care to patients under the direction of their Consultants.
Permanent hospital staff includes Registered Nurses, Health Care Assistants,
Operating Department Practitioners, Physios, Pharmacists, Radiographers,
administrative staff, caterers, housekeepers and porters.
All clinical and support staff have the relevant training and skills to fulfil their roles
and this is an ongoing process. There is also a Rivers Hospital Staff Bank which
provides extra support and flexibility to the service where needed.
The Rivers Hospital has worked closely with local Clinical Commissioning
Groups (CCG’s) in Hertfordshire and West Essex, to support commissioning of
healthcare services for the local NHS population. The hospital also has close
links with Princess Alexandra NHS Trust (Harlow) and East and North Herts NHS
Trust Hospitals (WGC and Stevenage), including histopathology services and
emergency transfer provision.
The Rivers employs a GP liaison officer to ensure local GPs are well informed
about the services offered at the hospital.
The hospital also provides a programme of educational seminars for healthcare
professionals including specialist sessions and basic life support.
The Rivers is closely associated with the Helen Rollason Cancer Charity, which
has a Holistic therapy centre and offices within the hospital site.
The hospital supports local schools, charities and associations through
sponsorship and fund raising events throughout the year.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, the Rivers Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
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Priorities for improvement
2.1.1 A review of clinical priorities 2013/14 (looking back)
We have continued to monitor patient feedback. We have endeavoured to
ensure patients receive written information on discharge and this remains
an ongoing objective.
We have continued to maintain and improve standards of care and patient
satisfaction levels and have increased the membership of our patient
group.
Robust systems have been put in place to move towards full compliance
with all training and development activities including e-learning. Staff
supervision is now more structured and evidenced.
We are using Riskman, our electronic incident and near-miss reporting
system to provide a clearer analysis of trends and there is more
involvement at department level in incidents/near- miss handling.
We have implemented Care of the Child competencies with our team
caring for paediatrics within the Hospital.
We have made good progress in promoting Safeguarding awareness
through training and development – this is an ongoing priority.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
We will be recruiting a Quality Improvement Lead who will ensure all audits
are undertaken in a timely manner and who will implement new systems
where the requirement arises to improve levels in both participation and
results. We will be able to monitor our improvement using statistical
evidence.
This priority will support improvement within the domains of patient safety
and clinical effectiveness.
We will be further developing our use of RISKMAN, our electronic incident
and near-miss reporting system. Training sessions are in place to support
this priority. We aim to use reports from this system to further monitor
trends against our own hospital and regionally. .
This priority will support improvement within the domains of patient safety
and clinical effectiveness.
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We are introducing a programme of development of our facilities, to
include additional parking spaces, an additional theatre, upgrading of
Consultant/Patient rooms.
This priority will support improvement within the domain of patient
satisfaction.
We will be continuing to raise Patient Customer Awareness through a
programme that all staff will be expected to attend. We will monitor
improvement through Patient Feedback statistics.
This priority will support improvement within the domain of patient
satisfaction.
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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 the Rivers Hospital provided and/or subcontracted 30 NHS
services.
The Rivers Hospital has reviewed all the data available to them on the quality of
care in all of these NHS services.
The income generated by the NHS services reviewed in 1 April 2013 to 31st
March 14 represents 100 per cent of the total income generated from the
provision of NHS services by the Rivers Hospital 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 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
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% Staff Turnover
% Sickness
% Lost Time
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Significant Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014 The Rivers Hospital participated in all
relevant national clinical audits and all relevant 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 the Rivers
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
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submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome
Review Programme
% cases
submitted
National Joint Registry (NJR)
Hips
76
Shoulders
25
Knees
83
Elective surgery - National Patient Reported Outcome
Measures Programme (PROMS):
34
Groin Hernias
45
Hip Replacement
29
Knee Replacement
NB The PROMS data is from March 2013 to December 2013 only.
The reports of all the above national clinical audits from 1 April 2013 to 31st March
2014 were reviewed by the Clinical Governance Committee and the Rivers
Hospital have taken actions to improve the quality of healthcare provided e.g. we
have looked at the process for PROMS with the view to increasing compliance.
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 the Rivers Hospital has
implemented action plans for each audit (where required) to improve the quality of
healthcare provided. 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.
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2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of the Rivers Hospital income in from 1 April 2013 to 31 March 2014
was conditional on achieving quality improvement and innovation goals agreed by
the Rivers Hospital and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
2.2.5 Statements from the Care Quality Commission (CQC)
The Rivers Hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your
Data Quality
The Rivers Hospital are in the process of introducing new outpatient pathway
(effective from 1 July 2014) and these will help improve Data Capture. An audit
programme will be implemented at the same time to analyse our findings.
NHS Number and General Medical Practice Code Validity
The Rivers Hospital submitted records during 2013/14 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which
are included in the latest published data. The percentage of records in the
published data which included:
The patient’s valid NHS number:
99.97% for admitted patient care;
99.96 for outpatient care; and
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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
The Rivers Hospital was not subject to the Payment by Results clinical coding
audit during 2013/14 by the Audit Commission.
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2.2.7 Stakeholders views on 2013/14 Quality Account
Dear Rivers Hospital,
Re: Quality Account 13/14
West Essex CCG (WECCG) has reviewed the information provided by the Ramsay Rivers Hospital
and believes this is a true reflection of the organisation’s performance during 2013/14, based on
discussions during the year as part of the on-going quality monitoring process.
The CCG also acknowledges the strong patient engagement, and focus on patient experience.
Overall a number of improvements have been made during 2013/14; however WECCG would like
to work with Ramsay Rivers Hospital to see significant focus and drive to ensure on-going
improvement in the quality of services delivered to patients.
WECCG looks forward to working with and supporting Ramsay Rivers Hospital in further
developing and monitoring the quality of the services it provides.
Yours Sincerely
Executive Director - Nursing, Quality & Patient Experience
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Interim Matron, Jan Rice
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.
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It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
Quality Accounts 2013/14
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National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
At Rivers we have reflected on the findings of the Francis, Keogh and Berwick
reports and intend to further reflect and scrutinise during 2014/2014.
3.1 The Core Quality Account indicators
Mortality:
Period
Best
Worst
2012/13
RKE
0.65
RXL
2013/14
RKE
0.63
RBT
Average
Period
Rivers
1.17
Eng
1
2012/13
NVC19 0
1.15
Eng
1
2013/14
NVC19 0
The Rivers Hospital has extremely low levels of deaths.
Expected Deaths:
Period
Best
Apr12
RBA
Mar13
Jul12 - Jun13 RBA
Worst
Average
Period
Rivers
0.1
RWH
44.0
Eng
20.4
2012/13
NVC19
0
0.0
RWH
44.1
Eng
20.2
2013/14
NVC19
0
The Rivers Hospital has not had any expected deaths.
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PROMS (Patient Related Outcome Measurements):
Hernia
Period
Apr12
Mar13
Apr13
Sep13
Best
-
Worst
Average
NT415
0.157 NVC27 0.015
Eng
0.085
RTG
0.138 RNA
Eng
0.086
0.019
Period
Apr12
Mar13
Apr13
Sep13
Rivers
-
NVC19 0.084
NVC19 *
This is a non obligatory questionnaire for patients to complete following their
surgery regarding their perception of the outcome of their surgery. No figures
were available for April to September 2013 due to the low percentage of
responses received.
Readmissions to Hospital:
Period
Best
Worst
2010/11
RF4
0.0
RYR
2011/12
RF4
0.0
RYR
Average
Period
Rivers
15.8
Eng
11.04
2012/13
NVC19
9.65
15.8
Eng
11.08
2013/14
NVC19
6.28
This shows our low overall percentage of readmissions after discharge.
Responsiveness to Personal Needs:
Period
Best
Worst
2011/12
RYR
73.3
RF4
2012/13
RYR
75.9
RJ6
Average
Period
Rivers
67.4
Eng
75.6
2012/13
NVC19
92.0
68.0
Eng
76.5
2013/14
NVC19
92.5
Average
Period
Rivers
This reflects our high overall percentage of patient satisfaction.
Venous Thromb Embolism Assessment:
Period
Best
Worst
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q3
NVC19
99.5%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
13/14 Q4
NVC19
99.4%
These figures show that the majority of patients have appropriate assessment
prior to surgery.
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Clostridium Difficile Rate (per 100,000 bed days):
Period
Best
Worst
2012/13
Several
0 RNA
2013/14
Several
0 RVW
Average
Period
Rivers
58.2
Eng
22.2
2012/13
NVC19
0.0
30.8
Eng
17.3
2013/14
NVC19
0.0
This shows our high standards of infection prevention; there have been no cases
to report.
Incident Rate (Patient Safety):
Period
Best
Worst
2011/12
RP6
2.6
TAJ
2012/13
RRF
2.0
RAT
Average
Period
Rivers
84.4
Eng
13.5
2012/13
NVC19
5.38
85.6
Eng
14.8
2013/14
NVC19
3.86
Data is managed on a daily basis and trends are identified where appropriate.
Serious Untoward Incidents (Severity 1 only):
Period
Best
Jul - Sep 12
NA
Oct11
NA
Sep12
Worst
Average
Period
Rivers
NA
NA
2012/13
NVC19
0.0%
NA
Eng
2013/14
NVC19
0.0%
11,563
This data is reflective of our extremely low SUI rate (severity 1 only).
Friends & Family Test:
Period
Best
Worst
Average
Jan-14
Several
100
RPA02
27
Eng
Feb-14
Several
100
RPA02
18
Eng
Period
Rivers
73
2012/13
NVC19 100
73
2013/14
NVC19 100
This is the percentage of our patients who would recommend the hospital to their
friends and family.
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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.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.2.1 Infection prevention and control
The Rivers 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.
Programmes and activities within our hospital include:
All staff are expected to attend their IPC mandatory training sessions or provide
evidence of having undertaken this training. Monthly Hand Hygiene audits are
completed to ensure compliance to policy.
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Infection Rates
Infection Rates
(percentage of Admissiosns)
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0
2011/12
2012/13
2013/14
Rivers Hospital
As can be seen in the above graph our infection prevention and control rate has
decreased over the last year and our level of infection is extremely low at
0.055%. Continuous monitoring is in place to ensure we maintain or decrease our
rate of infections in 2014/2015.
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 The Rivers 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. We
scored 100% in our audit undertaken in August 2013.
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.
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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.
We have made changes to processes in our training that has seen an increase in
attendance of mandatory training. We have increased our monitoring of local
audits that has led to an increase in the percentage of audits being undertaken.
3.3 Clinical effectiveness
The Rivers 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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Return to Theatre Score
Retrnn to Theatre
(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
Rivers Hospital
As can be seen in the above graph our return to theatre rate has decreased over
the last year.
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
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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:

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



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Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.4.1 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.
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Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
97.0
99.0
2012/13
2013/14
20
0
Rivers Hospital
As can be seen in the above graph our Patient Satisfaction rate has increased
over the last year to 99%.
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3.5 Rivers Hospital Case Study
Aquatic Therapy
At the Rivers Hospital we offer An Aquatic therapy service based at the Local
Country Hotel Spa but operated by the Rivers Physiotherapists.
Throughout the last year around 200 patients have attended these sessions with
an average attendance of three episodes.
The main patients attending are Post-Operative Back Patients who follow an
exercise programme that encourages a quick return to work.
It is also offered to other patients, one of the patients was someone who had
sustained multiple injuries due to an accident within the home. The patient
sustained a fractured pelvis and sacrum as well as upper limb fractures.
The patient was transferred to the Rivers for Rehabilitation two weeks after the
accident and once she was discharged home came as an outpatient to Aquatic
Therapy.
The Qualities of the water, Buoyancy and hydrostatic pressure, have been
extremely beneficial facilitating movement for the upper limb and allowing normal
Gait.
Three Months after the initial injury the Patient has made excellent progress, and
is walking with no aids. The upper limb injuries are also improving and the Patient
is progressing to a full Recovery.
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Appendix 1 – Clinical Audit Programme
2013/14.
Each arrow links to the audit to be completed in each month.
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The Rivers 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:
01279 600282
www.rivers-hospital.co.uk
Quality Accounts 2013/14
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