The Yorkshire Clinic
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK and The Yorkshire Clinic
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
1.3
Welcome to The Yorkshire Clinic
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2013/14 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health
Care UK
The Yorkshire Clinic 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 The Yorkshire Clinic hospitals annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people we
treat. It will also show that we regularly scrutinise every service we provide with a
view to improving it and ensuring that our patient’s treatment outcomes are the best
they can be. It will give a balanced view of what we are good at and what we need to
improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local community it
serves. Therefore, each site within the Ramsay Group now develops its own Quality
Account, which includes some Group wide initiatives, but also describes the many
excellent local achievements and quality plans that we would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Mike Flatley General Manager,
The Yorkshire Clinic
“The Yorkshire Clinic understands that you have a choice and is committed to
being the leading healthcare provider of choice by delivering high quality care
and outcomes for patients.”
This is the third Quality Account to be submitted by The Yorkshire Clinic and has
been produced to demonstrate our commitment to measuring all feedback from
patients about their experience, clinical treatment and clinical outcomes. This allows
us to continually review, reflect and improve the patient’s journey with aim of
becoming the healthcare provider of choice for all patients
We are aware that patients can be nervous about coming into hospital and
understand that providing reassurance is important to you the patient and your
family. This starts with patient safety, which is our highest priority. To this end we
recruit, induct and train our team to the highest standard in all aspects of care. This
approach extends to family and visitors in ensuring they are made to feel welcome at
the Yorkshire Clinic.
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The Yorkshire Clinic is committed to ensuring that patients are kept fully informed
about their treatment, which is also a significant factor associated with improving
treatment outcomes. We involve our patients in treatment decisions at the earliest
stage so that the options and benefits are fully discussed before patients consent to
treatment. Our medical and clinical teams recognise the importance of devoting time
preparing patients for surgery, which not only reduces risk but also improves patient
understanding and confidence, reduces anxiety, improves rates of recovery and
shortens lengths of hospital stay.
Whilst patient feedback and involvement is extremely important to us, we also rely
heavily on other measures of safety and clinical effectiveness which we use to satisfy
ourselves that treatment is evidence-based and delivered by appropriately qualified
and experienced doctors, nurses and other key healthcare professionals. Examples
of these are detailed in this Quality Account.
The Yorkshire Clinic is accustomed to the disciplines of regulatory and contractual
requirements to assure healthcare commissioners of our clinical performance and to
report complaints and serious incidents to regulators and commissioners. We also
maintain a Risk Register and systematically review specific actions to achieve risk
reduction.
The Yorkshire Clinic continually achieve consistent patient satisfaction scores of over
98% recommendation to others and for overall satisfaction and at time of writing is
showing one of the highest Friends and Families scores for any hospital Private or
NHS. By analysing the results throughout the year, we constantly seek ways to
further improve the patient experience.
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Mike Flatley
General Manager
The Yorkshire Clinic Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr James Halstead – Medical Advisory Committee Chair
Mr Richard Grogan - Clinical Governance Chair
Mr Stefan Andrejczuk – Regional Director North
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Welcome to The Yorkshire Clinic
The Yorkshire Clinic is a private hospital situated in the grounds of Cottingley Hall in
Bingley, West Yorkshire. The hospital offers care to patients with private medical
insurance, patients who wish to fund their own treatments and patient referred
through the NHS Patient Choice Scheme.
The hospital provides a full range of high quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months the hospital has treated 13,419 patients, 70.7% of
which were treated under the care of the NHS.
The Yorkshire Clinic has 339 members of staff with a split of 143 non-clinical staff
and 196 clinical staff.
The hospital has built excellent working relationships with local Commissioner and
Bradford Hospitals Foundation Trust, Leeds Teaching Hospital NHS Trust and
Airedale Foundation Trust in order to deliver a joint approach to patient care delivery
across the patient economy.
Our GP Liaison Officer provides links to local General Practitioners to ensure that
their needs and expectations are managed and through these links referral
processes are developed in order to streamline processes. The GP Liaison
Manager’s key role is to engage with local health care professionals within the
community to ensure they are fully aware of the services on offer at The Yorkshire
Clinic and have access to any information that can assist General Practitioner’s and
Medical Staff when referring into a secondary care provider. Part of the GP Liaison
officer’s role is to co-ordinate the post graduate programme which runs on a monthly
basis and covers a range of topics from orthopaedic to cardiology.
The Yorkshire Clinic also works with charities within the local community, hosting
events in their support.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, The Yorkshire Clinic 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. The
public inquiry at Mid Staffordshire NHS Foundation Trust is a stark reminder that
patients must come first with care delivered by compassionate and dedicated staff. At
the Yorkshire Clinic the patient experience is at the heart of everything we do within
the hospital. We want to know what matters to our patients, their relatives and carers
so we can enhance the quality of our services. Our quality improvement programme
focuses on three domains: patient experience, patient safety and the clinical
effectiveness of care and treatment. Our Quality Account seeks to provide accurate,
timely, meaningful and comparable measures to allow our partners to assess our
success in delivering our vision.
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Priorities for improvement
2.1.1 A review of clinical priorities 2013/14 (looking back)
Bar coding for patient identity bands – The Yorkshire Clinic electronically
prints all patient identity bands as per the NPSA ‘Standardising Wrist Bands
Alert’ issued in 2007. The need for Bar Codes on patients’ wristbands will
be reviewed by the Ramsay Information Governance Committee prior to the
proposed implementation date of September 2013.
Action taken: Patient wristbands at the Yorkshire Clinic now meet the
requirement of the information Standards Boards (2011) requirement for
GS1 compliance bar codes to be present on all bands
Safer Surgery Checklists – The WHO safe surgery checklist is in use for
all surgical procedures including cataract treatments and radiological
interventional procedures. This will continue to be a clinical priority and will
be audited regularly to identify any variance from the Ramsay policy.
Action taken: Audit has been completed on a monthly basis which
evidences compliance. Compliance results of the above audits are reported
to the Hospital/Unit Clinical Governance Committee, Group Clinical
Governance Committee and the hospital Medical Advisory Committee.
Cleanliness - Environmental audits will continue to be undertaken quarterly
as per Ramsay national audit programme. The hospital wide cleaning
matrix will continue, informing staff what needs cleaning when, with what
and by whom. The ‘Green label’ system is to remain, clearly evidencing to
patients when equipment has been cleaned by indicating the cleaning date
and the signature of the person who cleaned it. This year The Yorkshire
Clinic will take part in Patient Led Assessment of the Care Environment
(PLACE) which builds on the foundation of The Patient Environment Action
Team (PEAT) assessments, with two main differences:
Patients make up at least 50% of the assessment team giving patients
a much stronger voice.
Focus is on improvement with hospitals required to report publicly and
say how they plan to improve.
Action taken: The Yorkshire Clinic took part in the Patient Lead
Assessment of the Care Environment (PLACE) in May 2013. Results of the
audit are given below: Cleanliness 98%
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Food 91%
Privacy & Dignity 88%
Condition; Appearance and maintenance 91%
The PLACE audit in 2013 coincided with the hospital refurbishment programme on
the inpatient ward. Issues raised regarding appearance and maintenance have been
addressed as part of this programme. The patient journey is under continual review
through this process, patient feedback and our regular infection control audits to
address the issues raised in regards to privacy at Out Patient Registration reception.
The Report is available to download from www.efm.ic.nhs.uk
The PLACE audit for 2014 was undertaken on 28th April 2014. The results will be
available at the end of June 2014.
Joint Advisory Group (JAG) - The Yorkshire Clinic Endoscopy Suite will
continue to participate in the Global Rating Score audit system (GRS). In
March 2013 we had a JAG accreditation visit and were awarded a pass on
completion of some minor recommendations. We were given six months’
time frame to achieve these recommendations.
Action taken: In December 2013 we had a further accreditation site visit and
were awarded a pass. The Yorkshire Clinic now has full JAG accreditation. To
achieve accreditation the Yorkshire Clinic had to provide evidence that we had
met all the GRS standards (Global Rating Scale) and continue to monitor
moving forward to ensure continuous improvement in processes and patient
outcomes in the following:
o
o
o
o
o
o
o
o
Strengthen endoscopy services
Provide a knowledge base of best practices
Increase patient confidence in services
Improve the management and efficiency of services
Provide education on better/best practices
Provide comparison with self and others
Enhance the workforce, retention and satisfaction
Increase chances to add to and grow services
The competency skilled endoscopy team are supporting the development of
opening evening and weekend clinics in addition to a one stop endoscopy
service.
Day Case to OPD - The Yorkshire Clinic is introducing changes to improve
the patient experience throughout their journey on the day of surgery. In
2013 one of the main improvements being introduced is around ‘minor
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procedures’ being undertaken as an outpatient appointment rather than as
an in-patient. Selected procedures will be undertaken in our out patients
department under local anaesthetic which will greatly reduce the amount of
time patients need to spend in hospital. Procedures being considered for
this are hysteroscopy; cystoscopy and minor skin lesion procedures.
Action taken: Local anaesthetic cystoscopy, hysteroscopy and minor skin
lesion procedures are now undertaken as an outpatient pathway. The
Yorkshire Clinic has introduced a new technique for vasectomy which is
classed as a no injection, no scalpel and no suture vasectomy. This
procedure is undertaken in the outpatient department under a local
anaesthetic and is classed as an outpatient appointment.
Ligament Registry – The Yorkshire Clinic plans to participate in a National
Ligament Registry through our cohort of Orthopaedic surgeons performing
ligament surgery.
Action taken: The governance and data collection processes are currently
being established with a view to commence this in the autumn of 2014.
Friends & Family Test - A NHS-wide ‘friends and family’ test to improve
patient care and identify the best performing hospitals in England was
announced in 2012 by the Prime Minister.
From April 2013 patients at The Yorkshire Clinic have been invited to take
part in this anonymous survey. By completing a simple questionnaire asking
whether they would recommend our hospital to their family and friends.
Scores will be published on the NHS Choices Website www.gov.uk.
The Yorkshire Clinic ask all patients to complete the friends and family test
survey to enable us to collate patient opinion and act immediately upon any
concerns both for NHS patients and private patients. There is a
standardised approach to displaying the results at ward level, to ensure
transparency for patients. In addition to the score, the display also includes
a selection of the comments made. Negative comments are investigated
and actions taken to address issues highlighted. Below is a selection of
comments received from the Friends and Family Test questionnaires in the
last month:
‘All the people I came into contact with were helpful, professional and
efficient; a first class service’
‘Very clean and comfortable hospital, I could not fault anything’
‘Good level of care, friendly staff made all the difference’
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‘I have no complaints; everyone takes care to make your stay here
acceptable in every way’
Action taken: Alongside providing clinical excellence and safe care, patient
experience is the key measure of quality. The Yorkshire Clinic will use the
information received from our patients in this survey in order to improve the
service we offer. The Yorkshire Clinic has had excellent, positive feedback
following the introduction of the friends and family test. The scores indicate
that NHS day case and inpatients were extremely likely to recommend the
Yorkshire clinic to friends and family with a score of 93%. The scores
indicate that private patients were extremely likely to recommend the
Yorkshire clinic to friends and family with a score of 90%.
The Yorkshire Clinic continually achieves consistent patient satisfaction
scores of over 90% recommendation to others and for overall satisfaction
and at time of writing is showing one of the highest Friends and Families
scores for any hospital Private or NHS.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Clinical Effectiveness
The Yorkshire Clinic has a Clinical Governance team and committee that meet
regularly throughout the year to monitor quality and effectiveness of care.
Clinical effectiveness was chosen in order to evidence that the Yorkshire Clinic
are striving to strengthen governance by encompassing the following key
areas:
1.
2.
3.
4.
5.
6.
Francis report
Improved incident reporting
Continual & spot Audit
NHS Safety Thermometer Audit
PROMS ( Patient reported outcome measure Studies)
Cavendish Report and the strengthening of Health Care Assistant
Roles
Francis Report
In response to the Francis report on The Mid Staffordshire NHS Foundation
Trust’s Public Enquiry the Yorkshire Clinic are committed to ensuring that we
offer safe consistent practice and care by instigating regular audit practice,
monitor and review incident reports, take into account patient and staff
feedback and implement recommendations made. Staff training and
development is a key focus to ensure safe effective practice, professional
development reviews are instigated yearly and reviewed on a six monthly
basis to ensure development and learning has been achieved.
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Incident reporting
Clinical incidents, patient and staff feedback are systematically reviewed to
determine any trend that requires further analysis or investigation. More
importantly, recommendations for action and improvement are presented to
hospital management and medical advisory committees to ensure results are
visible and tied into actions required by the organisation as a whole.
Incident and near-miss reporting is encouraged to ensure effective learning in a
no blame culture. The Yorkshire Clinic intend to instigate clinical feedback
forums following incidents ensuring staff fully understand lessons learnt and
plan actions accordingly in order to address issues identified. The outcomes
will then be reported onto the Riskman site which is an instant reporting data
base and attached to individual incidents evidencing a robust investigation and
satisfactory outcome.
Audit
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme
(the schedule can be found in appendix 2) the audit topic and schedule is set
centrally by Ramsay Health Clinical Governance Committee to allow greater
opportunity for benchmarking. Additionally the Yorkshire Clinic also carries out
a number of local clinical audits all of which are discussed and reviewed
through the Clinical Governance Committee where actions are taken to improve
the quality of healthcare provided. The completion of local audits ensures
compliance is monitored and evaluated to ensure continuity of care and safe
effective practice. The Yorkshire Clinic intend to evaluate corporate audits and
local audit practice by completing action plans if the scores of audits fall within
95% or less of the rating score.
NHS Safety Thermometer
It was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve our
services. The Yorkshire Clinic carry out a VTE risk and falls assessment on all
admitted surgical patients as per Ramsay Policy No CM001 and adheres to
National Institute for Clinical Excellence (NICE) Guidance 2010. Compliance is
audited through a robust corporate and local audit programme and
results/action plans reviewed through Clinical Governance. Compliance results
are benchmarked through the National Statistics at:
http://transparency.dh.gov.uk/category/statistics/vte/
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PROMS
Increasing the use of Patient Reported Outcomes Studies (PROMs) – The
Yorkshire Clinic routinely issues the National PROMS questionnaires to patients
undergoing hip, knee, hernias and cataract surgery (PROMs for Hip’s, Knees
and Hernia Repairs are reported by The Yorkshire Clinic). These are used to
gain a better understanding of treatment outcomes from a patient point of view.
Compliance for PROMS is above the national average at The Yorkshire Clinic.
Consultants can access this information within their own Trusts for all patients,
including those treated at The Yorkshire Clinic. We continue to monitor
compliance return rate in order to ensure that we continue to learn from patient
feedback, we will be concentrating our efforts on this initiative throughout 2014
Cavendish Report
Following the Cavendish report in July 2013 and recommendations made
Ramsay Healthcare have implemented core competencies for health care
assistants (HCA’s) in order to ensure the care that they provide is safe and
consistent. The Yorkshire Clinic work closely with Shipley College who provide
NVQ training for support staff at levels one, two and three. Health care
assistant staff members are routinely assessed on site and support is offered by
both the college and the clinic to encourage further development. Ramsay
Healthcare has recently introduced a HCA core competencies portfolio training
package enveloping practical skills for further development. The portfolio will be
a living document containing evidence of clinical achievements, e.g. course
certificates, study day or conference attendances and will provide evidence to
support Care Quality Commission requirements. It is transferrable within
Ramsay Health Care hospitals/units and can be used as evidence for
professional registration. The core competencies are listed under the following
headings:
Observations
o
o
o
o
o
o
o
o
o
Temperature
Pulse
Respirations
Blood Pressure
Oxygen Saturation
Early Warning Score
AVPU
Urine output/Fluid Balance
Blood Glucose
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o
o
o
o
o
o
o
o
o
o
o
Nutrition and Hydration
Transfer of patients from ward to theatre
Ophthalmic pre admission tests
ECG
Basic dressing/removal of suture /clips
Venepuncture
Care of the intravenous site
End of life pathway
Documentation
Urinalysis
Height and BMI
Development is discussed at the induction stage, competencies are observed
by a mentor on a regular basis to ensure safe effective practice is achieved and
at professional development reviews which are instigated on a yearly basis with
a six monthly review to re assess development. HCA staff work alongside a
designated registered nurse on duty and are assigned tasks according to skill
level. All record keeping completed in a patient’s care pathway is read, checked
and signed by the delegated responsible lead nurse as per Ramsay Corporate
policy and procedure. Ramsay Healthcare provide designated uniforms for staff
members along with a name badge which includes the individual staff members
job title ensuring that patients can easily identify individual team members.
We are currently reviewing the process surrounding a theatre escort role for
HCA staff in order to build upon effective communication with theatre/ward staff
and the patient.
Patient Experience
The Yorkshire Clinic is committed to improving upon the service that our
patients experience. We endeavour to be the health care provider of choice for
all our patients. In order to accomplish this we aim to measuring feedback from
patients about their experience, clinical treatment and clinical outcomes.
We have chosen patient experience to evidence compliance in the following key
areas:
1.
2.
3.
4.
Patient Feedback
Customer Excellence Training
Ambulatory Day Care
Telephone Handling
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Patient Feedback
The Yorkshire Clinic asks all patients to complete the ‘We Value Your Opinion’
survey to enable us to collate patient opinion and act immediately upon any
concerns.
As a direct result of the comments received from the ‘We Value Your Opinion’
questionnaires the following are some examples of how we have improved care
within the hospital:
Patient comment: ‘Clean rooms, pleasant staff, the food was of a good
standard, well done’
1. Our Customer Services Manager and Chef regularly visit patients
following admission to discuss and receive feedback on the quality of
food and the options available. Our catering department are working
closely with the ward hostess team to ensure a consistent service is
delivered to a high standard.
2. Catering facilities refurbishment has taken place including replacement
of some equipment, both in the main kitchen area and the ward
serveries. An additional upgrade of some kitchen equipment has been
instigated and full replacement of crockery and patient bedside water
jugs has been actioned
3. A new menu will be launched mid-April 2014 with greater choice; in
addition to this service the new dishes will be launched on a new look
menu card
Patient comment: ‘Good level of care offered; I found parking to be difficult
when attending for outpatient appointments as the car park was very busy’
4. Additional parking has been sourced off site for members of staff giving
extra car parking spaces for our patients
We intend to continue to monitor patient feedback in order to build upon the
patient experience at the Yorkshire Clinic. We pride ourselves as being the
hospital of choice for all our patients and fully intend to continue to provide a
first class service.
We are participating in the National PLACE audit, the audit is set to take place
on Monday 28th April 2014. These assessments include rating of privacy and
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dignity, food and food service, access issues such as signage, bathroom / toilet
environments and overall cleanliness. Patients make up at least 50% of the
assessment team giving them a much stronger voice. The focus is on
improvement, with hospitals reporting publicly on how they plan to improve.
Ramsay Healthcare has embraced this initiative and value patient feedback, the
findings from this audit can be found at: http://www.england.nhs.uk/ourwork/qualclin-lead/place/.
We will disseminate the findings and instigate an action plan in order to address
issues raised.
Ramsay Healthcare is committed to improving facilities, the Yorkshire Clinic
continually strives to build upon and improve facilities for our customers and
outside stakeholders. Planning permission has been granted to extend the main
reception area at the front of the building incorporating a covered roof area for a
drop off/collection point, coffee and tea facilities along with a larger reception
and patient waiting area. With this in mind we intend to review the process
surrounding the registration of patients in order to provide a more streamlined,
private service.
Customer Excellence Training
Ramsay Healthcare has instigated a Customer Care Excellence service training
initiative throughout all Ramsay hospitals. The Yorkshire Clinic has two local
champions who attended training corporately; the first training programme for
customer care excellence was instigated locally in August 2012.
In order to raise continued staff awareness a further training session was
incorporated into the mandatory training programme as a refresher session.
The second stage of the corporate training programme is set to commence in
April 2014. This training enforces a raised awareness of patient perception and
expectation; reminding staff of the importance of consistent excellence in
customer care. The results of this training can be monitored through the patient
feedback satisfaction survey and the friends and family test. This training
programme will be instigated monthly and encompass all staff within the
hospital.
Ambulatory Day Care: - Better outcomes and improving patient experience:
Ambulatory Care or Day Care Surgery is the admission of selected patients
(both medical and surgical) to hospital for a planned procedure, returning home
the same day i.e. the patient does not incur an overnight stay. Over recent
years, partly due to medical advances the number of day surgery patients has
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increased compared to those requiring an in-patient stay.
percentage of day surgery patients we treated was 83%.
In 2013 the
In addition the Yorkshire Clinic has reviewed the procedures it performs as day
cases under local anaesthetic, and where appropriate has converted these
procedures to outpatient attendances to promote an earlier discharge from
hospital. This includes urological, gynaecological and some minor skin
procedures.
In the last twelve months the Yorkshire Clinic has developed a separate unit for
the treatment of ophthalmology patients, this ensures a walk in, walk out service
in a unit dedicated to ophthalmology. The unit comprises of a dedicated local
anaesthetic day case ophthalmology theatre as well as an outpatient facility
offering follow up support services.
At the Yorkshire Clinic we aim to ensure that 100% of our Ambulatory Day Care
patients will be treated following one of our ambulatory care pathways. In order
to achieve this The Yorkshire Clinic provides patients with a more efficient
journey through the hospital which includes procedure specific pathways. We
also have a dedicated ambulatory suite for patients who are having procedures
under local anaesthetic to reduce waiting times for these patients ensuring a
more streamlined efficient pathway.
We also have a dedicated day surgery facility that is separate from our inpatient facility, best practice has shown that this improves waiting times and
recovery periods are reduced. We monitor the ambulatory day care experience
through our patient satisfaction surveys. We have recently introduced local
anaesthetic, minor surgery for lumps and bumps within the outpatient
department converting the cases from a day case pathway to an outpatient
pathway. This service is more streamlined and less time consuming for the
patient. We will monitor this service moving forward by reviewing “we value your
opinion” survey results and the friends and family test.
Call Handling
The Yorkshire Clinic has recently introduced a new telephone call handling
service within the hospital. This service offers our customers a more efficient
call handling experience. We have introduced a private enquiry handling
service along with an NHS handling service ensuring that all calls are directed
to the appropriate department in a timely and efficient manner. The call handling
system directs NHS and Private customers to separate telephone hunt groups
rather than individual extensions to allow the customer to be transferred to the
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next available enquiry handler. These hunt groups consist of specialised NHS
enquiry handlers and specialised Private enquiry handlers to allow our customer
groups differing needs to be met in a timely manner and to allow consistency of
service excellence. The customers are also offered a call back option at their
convenience should they be waiting longer than 30 seconds. The system also
allows the Sales & Marketing Manager to review Key Performance Indicators
which are reported to the Senior Management Team such as; queue time, call
back requests and available handlers. It also allows additional enquiry handlers
to be made available quickly during peak times. We will monitor this service
moving forward to ensure that we continue to offer an excellent, efficient
service. On patient discharge, patients are advised to contact the ward if they
require any further advice. Patients receive discharge advice leaflets which
include contact details of the Yorkshire Clinic. We are currently reviewing the
aftercare call service for all NHS and private patients and intend to implement
an action plan to address this initiative moving forward.
Patient Safety
The Yorkshire Clinic is a progressive hospital focussed on improving its
performance every year, particularly with regard to patient safety. Risks to
patient safety are identified through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more
routinely from tracking trends in performance indicators.
We have chosen patient safety to evidence that the Yorkshire Clinic are
committed to improve upon patient safety initiatives already embedded within
the hospital by encompassing the following key areas:
1.
2.
3.
4.
5.
Falls
Never Events
Consent
Vulnerable adults/children
Prevent
Falls
To maximize patient safety our routine practice is that all patients are asked to
complete a medical questionnaire; this is assessed by the Pre-operative
Assessment Team to identify any potential risks prior to admission. Last year a
more detailed falls risk assessment was introduced and this has been in use for
all patients, this is reviewed daily and care altered accordingly. Information for
patients on how to minimize the risk of falls following surgery/ procedures is
available in the patient information folder in every room. The physiotherapy
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team have also provided falls prevention leaflets and classes are available to
any patient that has had a recent fall. Any slip, trip or fall is reported through
our robust electronic RISKMAN Reporting system identifying any trends,
formulating and implementing action plans across the hospital to help improve
patient safety.
Slips, trips and falls recorded/reported during 2012/13 were 26; the following
year in 2013/2014 there was a total of 16 falls reported throughout the hospital
which shows a marked improvement. All, staff are aware of the importance of
reporting all incidents including slips, trips and falls on the incident reporting
system. Despite the decrease in falls there are always practice changes that
can be reviewed to continue to minimise the risk of slips, trips and falls. Over
the past twelve months emphasis has been concentrated on:
Continuing staff training in risk assessment of patients specifically related to
movement and sensation of all aspects affecting limbs following surgery.
Effective implementation of the new falls risk assessment for all ward staff
Patient manoeuvres post-surgery are undertaken only following risk
assessment with two staff members of staff present.
Competency training provided by physiotherapists for all nurses & Health
Care assistants in specific risk assessment relating to the effects of regional
anaesthesia.
The figures show an increase in incident reporting, reflecting a raised
awareness and improved reporting of actual incidents onto our Riskman
reporting system. We will continue to monitor incidents and review feedback in
order to learn from lessons learned and instigate actions to prevent recurrence.
Never Events
Never events are serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been
implemented. The Yorkshire Clinic continually strives to ensure that patient
safety is at the forefront of every intervention.
All new staff members are introduced to a mentor and attend an induction
training session during their first few weeks in post. All staff are required to
complete a mandatory training programme on a yearly basis in order to reaffirm
processes and to raise awareness. Induction and mandatory training includes
health & safety, infection prevention and the reporting of incidents.
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We have robust policies and procedures in place informing staff members of the
need to adhere to guidelines to ensure both staff and patient safety. These are
held on the Ramsay intranet and are available for all staff to reference, and are
updated and introduced through a CAS alert process, cascaded to all staff
through Heads of Departments.
The reporting of incidents and near misses is encouraged and recorded onto an
electronic incident reporting data base called Riskman which enforce learning’s
surrounding individual incidents. All members of staff have access to this
reporting tool.
Despite all of the above, the Yorkshire clinic regrettably witnessed 2 never
events in relation to the insertion of the wrong size implant. The first involved
the insertion of a mismatched cup of an orthopaedic hip implant and the
second, the wrong strength of intra-ocular lens implant. These related to
different surgeons, different teams and both patients underwent successful
corrective surgery.
Both these incidents underwent detailed investigations which were shared with
the patients affected, Ramsay Clinical Board, Quality leads from our NHS
Commissioners, the Care Quality Commission, and all of our Surgeons and
staff. The details of which are described with learning’s on pages 24 & 25.
As an organization, considering there were 2 never events the following actions
in response have occurred.
o Matron enrolment on the NHS England Human behaviors workshop
programme.
o Specific Governance training completed by the Theatre manager.
o Creation of a dedicated clinical governance lead role
o Feedback forums to review incidents, audit and preventative actions.
o Additional Audit (random spot check) & independent audit by external
assessors.
o Introduction of a Ramsay UK wide Consultant incident database to
share incidents regarding consultant practice.
o Participation in NCAS ( National clinical assessment service )
Consent
Patient consent is a further safety initiative in order to ensure the correct
procedure is consented for by individual patients enforcing safe, effective
practice. Informed consent also ensures that the patient is fully aware of the
relevant procedure and the risks involved. Ramsay Healthcare has strict
guidance relating to informed consent and all staff members receive training on
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this safety element within the mandatory training programme. The Yorkshire
Clinic measure consent by undertaking an audit on a monthly basis to ensure
compliance by both staff members and Consultant practitioners.
The
monitoring of Informed consent will continue to be our focus for 2014/15 to
envelope and embed safe practice and standards.
Vulnerable Adults/Children
Vulnerable adult training ensures that our patients are safe and being cared for
by competent knowledgeable staff. The Yorkshire Clinic staff complete annual
mandatory training programmes, incorporated into this training programme is
vulnerable adult training. A flow chart has now been developed and is displayed
in each department; which provides quick access information for staff to know
who to contact or what to do if they have concerns regarding adult abuse
issues. The designated lead nurse for safeguarding vulnerable adults and
children is Amanda Cokell (Governance Lead). Safeguarding training is ongoing
within the unit and was chosen as a priority in order to ensure that we comply
with the Department of Health’s requirements surrounding safeguarding
vulnerable adults. Our compliance will be measured and reported to the head of
the safeguarding adult’s board along with the local CCG Commissioners in
order to monitor and share safe, effective practice with our stakeholders.
Prevent
The Yorkshire Clinic recognise that the Prevent agenda requires healthcare
organisations to work with partner organisations to contribute to the prevention
of terrorism by safeguarding and protecting vulnerable individuals who may be
at a greater risk of radicalisation and making safety a shared endeavour.
Ramsay Healthcare acknowledge that Prevent is central to the Safeguarding
agenda and as a priority has introduced Prevent training within Safeguarding
policies, procedures and mandatory training. Prevent training has recently been
introduced as an additional training package within the mandatory training
programme. The hospital has a designated lead nurse for Prevent and for
Safeguarding. Mandatory staff training is tracked in order to ensure all staff
have completed the mandatory training programme; ensuring awareness and
development. Prevent training is ongoing within the unit and was chosen as a
priority in order to ensure that we comply with the Department of Health’s
requirements surrounding safeguarding vulnerable adults. Our compliance will
be measured and reported to the Head of the Safeguarding Adults Board along
with the local CCG in order to monitor and share safe, effective practice with our
stakeholders.
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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 Yorkshire Clinic provided and/or subcontracted 17 NHS services.
The Yorkshire Clinic has reviewed all the data available to them on the quality of care
in all of these NHS services which include:

















Anaesthetics
Audiology
Dermatology
Dietetics
ENT
Gastroenterology
General Surgery
Gynaecology
Hand surgery
Neurology
Ophthalmology
Oral Surgery / Restorative Dentistry
Oral and Maxillo Facial
Orthopaedics
Pain Management
Sleep Studies
Urology
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard are
reviewed each year. The scorecard is reviewed each quarter by the hospitals senior
managers together with Regional and Corporate Senior Managers and Directors.
The balanced scorecard approach has been an extremely successful tool in helping
us benchmark against other hospitals and identifying key areas for improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient safety
and quality were:
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Human Resources
2011/2012
Total Health Care Assistants – whole 17.59
time equivalent (WTE)
Total Registered Nurses (WTE)
56.72
Total WTE Nursing (RN & HCA)
74.31
HCA hours as a % of Total Nursing
26.67%
Hours
Rolling Sickness Absence
4.53%
Rolling Employee Turnover
4.7 %
Number of Significant Staff Injuries
1 (RIDDOR
reportable)
2012/2013
21.97
2013/2014
22.55
56.75
78.72
28%
53.06
75.61
29.8%
3.66%
6.0%
1 (RIDDOR
reportable )
3.89%
11.8%
1(RIDDOR
reportable)
The ratio of qualified nurses to health care Assistants has altered recently due to
improvements in training and recruitment of Health care assistants to provide
additional competency skilled ability to more effectively support the Registered
nurses to deliver a higher quality of care.
The Yorkshire Clinic complete a Mandatory training programme for all staff members
including clinical and non clinical. Staff attendance is recorded to ensure compliance.
The training is instigated on a monthly basis throughout the year; the topics covered
are:
Customer Care
Fire
Prevent
Basic Life Support
Data Protection
Infection Prevention & Control
Manual Handling Non Clinical
The Yorkshire Clinic established a pathway to record the government friends and
family initiative within 2013/14. This has been embedded and the results have been
positive. A sample of November 2013, results are outlined below indicating that the
Yorkshire clinic achieved the highest test score of the North of England hospitals.
Quality Accounts 2013/14
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Friends and Family Test Score
The above table shows The Yorkshire Clinics score of patient who would recommend
the Yorkshire Clinic to friends and family against the other local providers. (November,
2013)
Friends and family response rate
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The above table shows The Yorkshire Clinics response rate against the other local
providers. (November, 2013)
Formal complaints:
The Yorkshire Clinic received 47 complaints from 1 April 2013 to 31 March 2014
compared to 61 complaints in the previous year. The 47 complaints were expressions
of concern, dissatisfaction and requests for action to be taken. Complaints received
were categorised as 20 medical complaints, 11 clinical complaints and 16 service
complaints. All of these were investigated meeting all of our timetables around
response. There were no common themes or significant concerns arising from the
complaints received. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care. Every complaint received is given
immediate attention of the General Manager and Matron on the day it is received,
following which a thorough investigation is commenced into the concerns raised as
per Ramsay Complaints Policy.
There were no EMSA (Eliminating Mixed Sex Accommodation) breaches throughout
2012/13.
‘Never Events’
Never events are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented. For further
details please visit: http://www.nrls.npsa.nhs.uk/resources/collections/never-events.
The core list of “never events” includes:
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post procedure.
Wrongly prepared high risk injectable medication
Maladministration of a potassium containing solution.
Wrong route administration of chemotherapy
Wrong route administration of oral /enteral treatment
Intravenous administration of epidural medication.
Maladministration of insulin
Overdose of midazolam during conscious sedation
Opiod overdose of an opiod naive patient
Inappropriate administration of daily oral methotrexate
Transfusion of ABO incompatible blood components.
Misplaced naso or oro gastric tubes.
Wrong gas administration.
Failure to monitor and respond to oxygen saturation.
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Air embolism.
Misidentification of patients
There were 2 never events at The Yorkshire Clinic during 2013/14.
Never event 1: Orthopaedic – Never event – 5th June 2013
A level 2 serious incident was reported on 5th June 2013 where an incorrect sized
femoral head implant was inserted during hip revision surgery. The patient underwent
planned hip revision surgery, following primary hip replacement surgery on
01.02.2013. The error was identified by the Consultant Surgeon as he was recording
his operation notes immediately following surgery and was reported to the Theatre
and Ward Managers at that point.
The surgeon explained that he had, during a difficult revision hip replacement
procedure implanted a 28mm acetabular liner, into this liner he should have inserted
a 28mm head but had inserted a 32mm head by mistake. A comprehensive
investigation was undertaken to establish the root cause, actions and learning’s in
order to prevent recurrence. The patient and family were fully informed, the incident
was reported to the Governance and Risk Senior Associate at West and South
Yorkshire and Bassetlaw commissioning support unit with STEIS notification. The
incident was reported to Ramsay Central Clinical Governance Lead via the Ramsay’s
Riskman system. The Care Quality Commission was also notified of this incident as
per policy and procedure. The patient has since received further corrective surgery
with a successful outcome.
A thorough investigation was instigated identifying analysis, findings, root cause,
lessons learned and actions to prevent recurrence. Recommendations and an action
plan were instigated, a planned Practice Review Advisory Committee meeting
(PRAC) regarding the consultants practice occurred in line with Ramsay Facility
Rules.
Never event 2: Ophthalmology – 30th December 2013
A level 2 serious incident was reported on 30th December 2013 where an incorrect
sized intra ocular lens was inserted, affecting an NHS patient whilst undergoing
phacoemulsification with intra-ocular lens replacement in the right eye on the
18.12.13. A comprehensive investigation was undertaken to establish the root cause,
actions and learning’s in order to prevent recurrence. The patient and family were
fully informed, the incident was reported to the Governance and Risk Senior
Associate at West and South Yorkshire and Bassetlaw commissioning support unit
with STEIS notification. The incident was reported to Ramsay Central Clinical
Governance Lead via the Ramsay’s Riskman system. The Care Quality Commission
was also notified of this incident as per policy and procedure.
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The patient has since received further corrective surgery with a successful outcome.
A thorough investigation was instigated identifying analysis, findings, root cause,
lessons learned and actions to prevent recurrence.
Recommendations and an
action plan were instigated with immediate effect, compliance to adhere to pre
surgery checks in line with Ramsay policy continues to be audited to ensure safe
effective practice.
2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014, 5 national clinical audits and 5 national
confidential enquiries covered NHS services that the Yorkshire Clinic provides.
During that period the Yorkshire Clinic participated in 5 national clinical audits and did
not participate in any national confidential enquiries.
The national clinical audits and national confidential enquiries that the Yorkshire
Clinic participated in, and for which data collection was completed during 1 April 2013
to 31st March 2014, are listed below alongside the number of cases submitted to
each audit or enquiry as a percentage of the number of registered cases required by
the terms of that audit or enquiry.
Name of Audit
Cardiac Arrest (National
Cardiac Arrest Audit)
Hip, Knees and ankle
replacement (National Joint
Registry)
Elective Surgery (National
PROMs programme)
Participation
(NA, No, Yes)
N/A
Yes
Yes
Health Protection Agency –
Surgical Site Surveillance
Yes
NHS Safety Thermometer
Yes
% cases
submitted
Comments
N/A
92%
Outcome snapshot provide on fig 1.
100% (as
recorded at
Feb 14)
Hip & Knee
Replacement
100%
All the above reports are discussed at the local clinical governance committee
meetings to ensure no trends are developing and outliers are highlighted.
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A snapshot of the National PROM’S outcomes is highlighted below:
Fig 1
(HSCIC, 13/02/14)
The reports of 5 national clinical audits from 1 April 2013 to 31 st March 11 2014 were
reviewed by the Clinical Governance Committee and the Yorkshire Clinic intends to
take the following actions to improve the quality of healthcare provided:
National Audits
A list of the national clinical audits we intend to undertake within the period 01 April
2014 to 31 March 2015 are as follows:
Name of audit / Clinical Outcome
Review Programme
National Joint Registry (NJR) – Per patient
Elective surgery (National PROMs Programme)
JAG Census – Quarterly
SSI – Surgical Site Surveillance – Quarterly
Local Audits
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme (the
schedule can be found in appendix 2) the audit topic and schedule is set centrally by
Ramsay Health Clinical Governance Committee to allow greater opportunity for
benchmarking. Additionally the Yorkshire Clinic also carries out a number of local
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clinical audits all of which go through the Clinical Governance Committee where
actions are taken to improve the quality of the healthcare provided:Infection Prevention Audits: The Yorkshire Clinic has followed the corporate
audit programme throughout the year and results have shown improvement in
hand hygiene and care of peripheral venous catheter with scores rising to
100% and 99% respectively.
Emergency Trolley Audit: To ensure that emergency equipment is ready for
immediate use, a check of the defibrillator, oxygen and suction is undertaken
daily. There is also a weekly audit of the critical care trolley.
WHO – surgical safety check audit: This is incorporated into the care record
for every patient and there is an additional audit to monitor compliance with
the checklist. The audit assesses that clinical staff are routinely checking that
the correct patient, receives the correct surgery on the correct site, and the
patient has been appropriately prepared and consented for the procedure
planned.
Consent Audit: Assesses the consent process in 2 stages. Stage one
ensures that patients are provided with sufficient information to provide
informed consent. Stage two confirms that the patient is happy to proceed
having had time to consider the information provided.
Clinical Variances & Outcomes: All clinical variances indentified where
there is a variance from the norm, i.e. extended length of stay, readmission to
hospital or return to the operating theatre are documented and reported, to
support a review and discussion in monthly clinical governance forums and
Medical advisory committees. These forums which are held by a group of
experienced clinician’s, support the discussion of trends and concerns relating
to practice in general or the practice of an individual practitioner and advice
and changes in practice can be implemented.
2.2.3 Participation in Research
There were no patients recruited to participate during 2013/14 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 Yorkshire Clinic income in from 1 April 2014 to 31st March 2015
was conditional on achieving quality improvement and innovation goals agreed The
Yorkshire Clinic 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.
Indicator Goal
1
Friends and Family
: increased response
rate (FFT)
2
Systm One - nonADT EPR Core
implemented at The
Yorkshire Clinic
Quality
Domain
Clinical &
Quality
Effectiveness
Clinical/Quality
Effectiveness
Description of
indicator
Increase the
response rate
from patients
To enable YC
access to the
same standard
platform as the
local GP
practices and
trusts
Indicator
Weighting
0.5%
2.0%
2.2.5 Statements from the Care Quality Commission (CQC)
The Yorkshire Clinic Hospital is required to register with the Care Quality
Commission and its current registration status on 31st March is registered without
conditions.
The Yorkshire Clinic was last inspected on the 29 January 2014. Three inspectors; 2
CQC inspectors & a Department of health inspector attended the site visit and
inspected 5 standards:
Consent to care and treatment
Care and welfare of people who use services
Safety and suitability of premises
Staffing
Assessing and monitoring the quality of service provision
Each of these standards was fully compliant and patient feedback to the inspectors
was:
Quality Accounts 2013/14
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"The nurses were lovely and they were happy with the whole process”
"Staff attitude is fantastic and nothing is too much trouble."
"Everything had been excellent".
"Things have been better than their previous stay four years earlier."
"There was good patient focus and the premises were very good."
2.2.6 Data Quality
The Yorkshire Clinic hospital will be taking the following actions to improve data
quality.
Good quality information underpins the effective delivery of patient care and is
essential if improvements in quality of care are to be made. Improving data quality,
which includes the quality of ethnicity and other equality data, will thus improve
patient care and improve value for money. On induction our staff are trained on how
to obtain and input data correctly onto our electronic systems and also how to handle
it confidentially, staff are monitored on correct data capture via internal reports and
data quality training is updated regularly throughout the hospital.
At The Yorkshire Clinic data quality is one of our highest priorities to ensure we
produce clean and accurate electronic data which we can use to monitor and improve
our quality of care and service. Throughout the year we have updated and
strengthened our processes to capture data in a timely manner and to audit data
prior to submission. We are constantly looking to improve data capture and reporting
processes supported by a dedicated corporate quality team.
NHS Number and General Medical Practice Code Validity
The Yorkshire Clinic hospital submitted records during 2013/14 to the Secondary
Users 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 was correct:
99.97% for admitted patient care;
99.96%for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was correct for
100% for admitted patient care;
Quality Accounts 2013/14
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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
The Yorkshire Clinic employs a full time Clinical Coder who is responsible for all
procedure coding. Internal clinical coding audits are performed on a regular basis
and all coders are required to undertake regular training and development to ensure
all changes in coding are identified and embedded into our processes.
The Yorkshire Clinic hospital was not subject to the Payment by Results of the
clinical coding audit during 2013/14 by the Audit Commission.
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2.2.7 Stakeholders views on 2013/14 Quality Account
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Yorkshire Clinic (YC) 2013-2014 Quality Accounts
Statement by Healthwatch Bradford and District Care Quality Working Group (CQWG)
The CQWG wishes to put on record its thanks to the Yorkshire Clinic’s Clinical
Government Lead for her helpfulness and we commend Ramsay Health Care on their
decision to produce a separate Quality Account (QA) for each of their hospitals detailing
local work on developing the quality of care.
These Quality Accounts have a clear and thoughtful introduction e.g. showing good
awareness of the need to deal with patient anxieties and careful attention to staff
recruitment, support and training.
We applaud the commitment to the principle of keeping patients fully involved in, and
informed about, their treatment. We urge that the YC carefully analyse patient feedback
to assist them in developing their practice in this respect and to ensure that patients are
aware that this is their right and that it is helpful to the outcome of their treatment.
We congratulate the YC on their work in:
reducing falls;
the continuing good work in infection control;
the thoroughness of their safety audits;
an excellent response to the Family and Friends question;
high staff awareness of the use of the Riskman Reporting system;
developing a system of bar-coded patient identify bands;
continuing to provide high standards of catering;
developing staff support and mandatory training; and,
planning for improvements in the reception area (though planning permission
appears to have been obtained prior to consideration of the need for privacy at
registration rather than this being a driver of these improvements)
Quality Accounts 2013/14
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We applaud the use of a no-blame approach to ensure positive encouragement is given
to incident and near-miss reporting. We urge a thorough use of root cause analysis to
ensure that where problems arise, systems and practices are overhauled to reduce the
chances of mishaps recurring
We were concerned that the lowest score achieved in PLACE feedback was on privacy
and dignity though we were pleased to see the consequent action taken in the
Outpatient Registration area.
We are very pleased to see the work with Shipley College in training Health Care
Assistants (HCAs) though we continue to have concerns about the declining proportion
of Registered Nurses. It would be useful to have data provided about nurse to patient
ratios in the in-patient areas although we must place on record the fact that the YC
provide better information on staffing than we find in most QAs.
We were concerned to hear about the number of complaints – but are confident that
these are systematically addressed. The practice of bringing all complaints immediately
to the attention of the General Manager and the Matron is excellent.
We were, of course, concerned about the Never Events reported but impressed by the
honesty with which these were addressed.
We feel that Patient Reported Outcome Measures (PROMs) could be more clearly
explained but very much welcome the level of detail provided. The lay reader needs to
know whether a high number is a good or a bad result. Like-for-like comparisons were
not always presented e.g. YC scores for the last year were compared to national scores
for previous years in the table presenting PROMs scores on readmissions and
responsiveness to personal needs. We did not understand what the indicators showed
on the measure of expected deaths. In any case, it seems that the scores are largely
impressive. Although there has been a worsening of readmission rates we can see that
the Yorkshire Clinic is addressing this issue.
We welcome the information provided on what has been learned from patient feedback
– the list of routes whereby this was obtained was useful although we think the QA
would be improved by the inclusion of patient stories and being told what was learned
from focus groups.
This is a clearly written and well presented document that shows the good work YC
continues to deliver, although we feel that there is a need for a glossary in this QA
explaining technical detail and organisational remit.
Quality Accounts 2013/14
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Part 3: Review of quality performance
2013/2014
Statements of quality delivery
Matron, Jill Campbell-Ainger
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our performance
on many levels, we reflect on the valuable feedback we receive from our patients
about the outcomes of their treatment and also reflect on professional opinion
received from our doctors, our clinical staff, regulators and commissioners. We listen
where concerns or suggestions have been raised and, in this account, we have set
out our track record as well as our plan for more improvements in the coming year.
This is a discipline we vigorously support, always driving this cycle of continuous
improvement in our hospitals and addressing public concern about standards in
healthcare, be these about our commitments to providing compassionate patient
care, assurance about patient privacy and dignity, hospital safety and good outcomes
of treatment. We believe in being open and honest where outcomes and experience
fail to meet patient expectation so we take action, learn, improve and implement the
change and deliver great care and optimum experience for our patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care
UK)
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care, clinicians
are enabled to provide that care and the organisation can satisfy itself that we are
doing the right things in the right way.
Quality Accounts 2013/14
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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.
3.1 The Core Quality Account indicators
Expected Deaths
Period
Apr12 - Mar13
Jul12 - Jun13
Best
RBA
0.1
RBA
0.0
Worst
RWH
44.0
RWH
44.1
Average
Eng
20.4
Eng
20.2
Period
2012/13
2013/14
Yorkshire
NVC20
50.0
NVC20
75.0
*The requested data is for the percentage of patient deaths coded as palliative.
Related NHS Outcomes
Framework Domain
The data made available to the National 1: Preventing People from dying
Health Service trust or NHS foundation trust by prematurely
the Health and Social Care Information Centre 2: Enhancing quality of life for
with regard to—
people with long-term conditions
(a)
the value and banding of the summary
hospital-level
mortality
indicator
(“SHMI”) for the trust for the reporting
period; and
(b)
The percentage of patient deaths with
palliative care coded at either diagnosis
or specialty level for the trust for the
reporting period.
*The palliative care indicator is a contextual
indicator.
Prescribed Information
The Yorkshire Clinic considers that this data is as described for the following
reasons:
In addition to providing surgical care and treatment, The Yorkshire Clinic provides
care and treatment for patients with long term chronic medical conditions and end
stage cancer under the care of Consultant Oncologists and Physicians. Most of
these patients choose to be cared for at the hospital on an end of life pathway during
Quality Accounts 2013/14
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the end stage of their disease process. The table explains the number of expected
deaths that have occurred at the hospital in the last year.
The Yorkshire Clinic has taken the following actions to monitor this rate, and
so the quality of its services by:
Completion of Corporate audits, incident investigation, root cause & gap
analysis of care episodes.
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Governance is also shared at local Medical advisory
committee and risk management meetings.
PROMS (Patient reported outcome measures)
PROMS:
Hernia
PROMS:
Hips
PROMS:
Knees
Period
Apr12 Mar13
Apr13 Sep13
Best
0.157
NVC27
0.015
Eng
0.085
RTG
0.138
RNA
0.019
Eng
0.086
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
Average
NT415
Period
Apr12 Mar13
Apr13 Sep13
Worst
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
Period
Apr12 Mar13
Apr13 Sep13
Period
Apr12 Mar13
Apr13 Sep13
Yorkshire
NVC20
0.079
NVC20
0.108
Yorkshire
NVC20
22.879
NVC20
*
Yorkshire
NVC20
16.411
NVC20
*
(* denotes insufficient data for publishing from the 2 questionnaires following case-mix adjustment by the NHS
data centre, which could be as a result of insufficient return of one of both of the questionnaires, in completed
questionnaires, NHS number omission)
Outlined in table above are the patient reported outcomes for The Yorkshire Clinic.
This is compared to the national best, worst and average scores from the UK.
Quality Accounts 2013/14
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The data made available to the National Health Service trust or 3: Helping people to
NHS foundation trust by the Health and Social Care Information recover from episodes of
Centre with regard to the trust’s patient reported outcome ill health or following injury
measures scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery,
during the reporting period.
The Yorkshire Clinic considers that this data is as described for the following
reasons:
The Yorkshire Clinic participates in the Department of Health PROM’s survey for hip,
knee and hernia surgery for NHS & private patients. As evidenced in the template
above the Yorkshire Clinic demonstrate compliance for PROM’s participation rate is
above the national average at the Yorkshire Clinic. As demonstrated PROMs
indicate a patient’s health status or health-related quality of life from the patient’s
perspective, based on information gathered from a questionnaire that patients
complete before and after surgery. PROMs offer an important means of capturing the
extent of patients’ improvement in health following ill health or injury.
The Yorkshire Clinic has taken the following actions to improve this score so
the quality of its services can be consistently monitored:
We continue to monitor compliance return rate in order to ensure that we
continue to learn from patient feedback, we will be concentrating our efforts on
this initiative throughout 2014.
Completion of Corporate audits, incident investigation, reporting, root cause
and gap analysis
Robust mandatory training programme compliance
Information sharing at ward level, raising staff awareness of the importance of
compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Also through local Medical advisory committee and Risk
management meetings.
Strict adherence to infection control policies
Readmissions
Period
2010/11
2011/12
Best
RF4
0.0
RF4
0.0
Worst
RYR
15.8
RYR
15.8
Average
Eng
11.04
Eng
11.08
Period
2012/13
2013/14
Yorkshire
NVC20
3.43
NVC20
7.6
Quality Accounts 2013/14
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The data made available to the National Health Service 3: Helping people to recover
trust or NHS foundation trust by the Health and Social from episodes of ill health or
Care Information Centre with regard to the percentage of following injury
patients aged—
(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital which forms part of the trust
within 28 days of being discharged from a hospital which
forms part of the trust during the reporting period.
The Yorkshire Clinic considers that this data is as described for the following
reasons:
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness & outcomes. As with return to theatre, any emerging trend identified
with a specific surgical operation or surgical team may identify contributory factors to
be addressed. As evidenced in the template above the Yorkshire Clinic demonstrate
readmission rates are below the average national rate compared to other sites and
this, in part, is due to sound clinical practice & governance ensuring patients are not
discharged home too early after treatment, are independently mobile and that
patients are fully informed of individual discharge information.
The Yorkshire Clinic has taken the following actions to improve this score so
the quality of its services can be consistently monitored:
Completion of Corporate audits, incident investigation, reporting, root cause
and gap analysis
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Also through local Medical advisory committee and Risk
management meetings.
Strict adherence to infection control policies
Responsiveness to personnel needs
Period
2011/12
2012/13
Best
RYR
73.3
RYR
75.9
Worst
RF4
67.4
RJ6
68.0
Average
Eng
75.6
Eng
76.5
Period
2012/13
2013/14
Yorkshire
NVC20
94.5
NVC20
95.0
The data made available to the National Health Service 4: Ensuring that people have
trust or NHS foundation trust by the Health and Social a positive experience of care
Care Information Centre with regard to the trust’s
responsiveness to the personal needs of its patients
during the reporting period.
Quality Accounts 2013/14
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The Yorkshire Clinic considers that this data is as described for the following
reasons:
Feedback from patients regarding their experience at The Yorkshire Clinic is
encouraged and is essential to inform our staff how care can be enhanced or
adjusted to meet individual patient satisfaction. All positive feedback is relayed to the
relevant staff to reinforce good practice and behaviour – letters and cards are
displayed for staff to see in staff rooms and on notice boards. Managers ensure that
positive feedback from patients is recognised and any individuals mentioned are
praised accordingly.
All negative comments or suggestions for improvement are also communicated to the
relevant staff using direct feedback. All staff are aware of our complaints procedures
should our patients be unhappy with any aspect of their care. Every complaint
received is given immediate attention of the General Manager and Matron on the day
it is received, following which a thorough investigation is commenced into the
concerns raised as per Ramsay Complaints Policy.
Patient experiences are received from the various routes listed below, and are
regular agenda items on Local Governance Committees for discussion, trend
analysis and further actions as necessary. Escalation and further reporting to the
Ramsay Corporate Governance Team, our stakeholders and regulatory bodies
occurs as required in line with Ramsay Healthcare and Department of Health policy.
The Yorkshire Clinic has taken the following actions to improve this score, and
so the quality of its services, by:
Feedback regarding the patient’s experience is received through the following routes:
Patient satisfaction surveys
We value your opinion questionnaire leaflet
Direct verbal feedback to Ramsay staff.
Internal Ramsay audit /inspection processes.
CQC inspection feedback.
Written feedback via letters/emails/complaints
Patient focus groups
PROMs surveys
Care pathways – patients are encouraged to read and participate in their
plan of care.
Annual PLACE patient audit
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Venous thromboembolism (VTE)
Period
13/14 Q3
13/14 Q4
Best
Worst
Several 100% NT244 63.2%
Several 100% NT205 67.0%
Average
Eng 95.8%
Eng 96.0%
Period
13/14 Q3
13/14 Q4
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.
Yorkshire
NVC20 98.7%
NVC20 99.0%
5: Treating and caring for
people in a safe
environment and
protecting them from
avoidable harm
The Yorkshire Clinic considers that this data is as described for the following
reasons:
The Yorkshire Clinic carry out a VTE risk assessment on all admitted patients as per
Ramsay policy which is based upon the National Institute for Clinical Excellence
(NICE) Guidance 2010. Our pre assessment team complete a VTE competency
assessment via the Department of Health on line assessment tool.
The Yorkshire Clinic has taken the following actions to improve upon and
maintain this score by:
Completion of Corporate audits, incident investigation, reporting, root cause
and gap analysis
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Also through local Medical advisory committee and Risk
management meetings.
Strict adherence to infection control policies
Clostridium Difficile Infection
Period
2012/13
2013/14
Best
Several
0
Several
0
Worst
RNA
58.2
RVW
30.8
Average
Eng
22.2
Eng
17.3
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.
Period
2012/13
2013/14
Yorkshire
NVC20
0.0
NVC20
0.0
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Quality Accounts 2013/14
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The Yorkshire Clinic considers that this data is as described for the following
reasons:
An annual strategy for Infection Prevention and Control (IPC) is developed at a
corporate level by the Group IPC and policies are revised and redeployed every two
years. IPC programmes are designed to bring about improvements in performance
and practice.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and best clinical practice. Within
the Yorkshire Clinic we have infection control link nurses in all clinical areas ensuring
that IPC management remains high priority throughout the hospital.
Healthcare associated infections (HCAI) are acquired as a result of healthcare
intervention. High standards of Infection Prevention and Control practice minimise the
risk of occurrence of HCAIs.
The Yorkshire clinic has taken the following actions to maintain this score, and
so the quality of its services, by:
The Local IPC Committee is chaired by our Consultant Microbiologist and
consists of representatives from all areas of the hospital. The committee
meets quarterly to oversee implementation of corporate policies and National
guidance and review clinical audit & practice. Minutes from local meetings
develop and review action plans to address issues identified in both the
corporate and local annual strategy/plan for infection control.
All staff undertake mandatory infection prevention and control (IPC) training
annually plus the clinical staff receive bi-annual Infection Prevention and
Control training/updates from our Consultant Microbiologist
Completion of Corporate clinical audits, incident reporting, identifying trends
and identification of further training requirements
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Also through local Medical advisory committee and Risk
management meetings.
Incident rate and patient safety
Period
2011/12
2012/13
Best
RP6
2.6
RRF
2.0
Worst
TAJ
84.4
RAT
85.6
Average
Eng
13.5
Eng
14.8
Period
2012/13
2013/14
Yorkshire
NVC20
4.55
NVC20
3.95
Quality Accounts 2013/14
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The data made available to the National Health Service trust or
NHS foundation trust by the Health and Social Care
Information Centre with regard to the number and, where
available, rate of patient safety incidents reported within the
trust during the reporting period, and the number and
percentage of such patient safety incidents that resulted in
severe harm or death
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
The Yorkshire Clinic considers that this data is as described for the following
reasons:
The Yorkshire Clinic strives to report any incidents or near misses in real time
through an electronic incident reporting tool called “ Riskman”. Every incident is
promptly reviewed by Matron and an investigation process, root cause analysis and
action plan implemented where appropriate. The Riskman system immediately
reports incidents directly to the Corporate Risk Management Team allowing the
identification of trends at the Yorkshire Clinic and throughout the Ramsay
organization to further identify trends and outlying data. Locally all incidents are
reported through Risk Management and Clinical Governance committees, learning’s
and action plans are developed and implemented at a local level to improve safety.
Other National reporting mechanisms e.g. MHRA; CQC; NHS England CAS alerts
and local NHS networks are used via the Ramsay CAS alert process to share
information with frontline staff as and when this is updated.
We recognise that we have scored above the national average due to robust
processes in place however; the Yorkshire Clinic has taken the following
actions to improve upon this score, and so the quality of its services, by:
Maintaining a robust staff induction and mandatory training programme
Monthly Risk management and Clinical Governance meetings are instigated
where risk key performance indicators and incidents are discussed and
disseminated
Continuing staff training in risk assessment of patients specifically related to
movement and sensation of all aspects affecting limbs after surgery.
Effective implementation of the new falls risk assessment for all ward staff
Competency training provided by physiotherapists for all nurses & Health
Care assistants in specific risk assessment relating to the effects of regional
anaesthesia.
Riskman introduction training updates via web based rolling programme
Quality Accounts 2013/14
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Friends and Family Test
Period
Jan-14
Feb-14
Best
Several 100
Several 100
Worst
RPA02
27
RPA02
18
Average
Eng
73
Eng
73
Period
2012/13
2013/14
Yorkshire
NVC20
92
NVC20
91
Friends and Family Test - Question Number 12d – Staff – The 4: Ensuring that people have
data made available by National Health Service Trust or NHS a positive experience of care
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.
The Yorkshire clinic considers that this data is as described for the following
reasons:
A NHS-wide ‘friends and family’ test to improve patient care and identify the best
performing hospitals in England was announced in 2012 by the Prime Minister.
All patients at The Yorkshire Clinic are routinely invited to take part in this anonymous
survey. By completing a simple questionnaire asking whether they would recommend
our hospital to their family and friends. Scores are published on the NHS Choices
Website www.gov.uk
Alongside providing clinical excellence and safe care, patient experience is the key
measure of quality. The Yorkshire Clinic will use the information received from our
patients in this survey in order to improve the service we offer.
The Yorkshire Clinic has taken the following actions to improve this score, and
so the quality of its services, by:
Continue to raise awareness of staff of the importance of patient feedback by
highlighting results through Clinical Governance meetings, staff meetings and
Customer Care Excellence training
Review the feedback and instigate action plans to address issues highlighted
Refresh notice boards in patient areas with recent results and action plans
instigated to address issues
Track and record robust induction and mandatory training to ensure raised
staff awareness of the friends and family test
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record for
patient safety.
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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 Yorkshire Clinic 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.
As can be seen in the above graph our infection rate has remained static for 2013/14.
Programmes and activities within our hospital include:
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The Yorkshire Clinic understands that Infection Control is a core part of an effective
risk management programme, aiming to improve the quality of patient care and the
occupational health of staff, in addition to the clinical need to prevent Healthcare
Associated Infections (HCAI), and protect patients from harm.
The Yorkshire Clinic infection control processes are coordinated and led by an
experienced Registered Nurse. The Yorkshire Clinic Infection Prevention & Control
Committee comprises of Consultant Microbiologist, Infection Control Lead; Hospital
Matron; CSSD Supervisor; Hospital Engineer; Hotel Services Manager; Pharmacy
Manager and Link Nurses from Theatre, Wards, Outpatients and Endoscopy.
Meetings are held quarterly and provide the hospital with infection prevention advice
and guidance in conjunction with Ramsay Infection Prevention & Control Policies and
Procedures and National Guidance. All staff undertake mandatory annual e-learning
and practical training sessions for Infection Prevention and our Consultant
Microbiologist also provides bi-annual in house training. A comprehensive infection
control audit programme has been maintained throughout 2013/2014.
Audits undertaken during 2013/14 achieved average scores of: PEAT
96 %
Hand hygiene
100%
Environment cleanliness
95%
Surgical site infection
100%
Peripheral venous catheter care
93.5%
Urinary catheter care
99.5%
The Infection Prevention & Control Audits have shown improvement in the following
areas: Improvement with Surgical Site Infection practices have been seen with audit
results consistently at 100% throughout 2013/14
Staff development training for surgical site Infection data collection (SSI) has
been organised to ensure robust compliance is adhered to
The Yorkshire Clinic regularly audits surgical site infections across surgical
specialities using the Department of Health (2010) High Impact Intervention
care bundle tool, to prevent surgical site infection. This audit focuses on the
Quality Accounts 2013/14
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pre-operative and peri-operative practice. The audit results during 2013/2014
were 100% compliance.
Action plans are in place to address all of the issues raised in all the above audits
where compliance is less than 95% and are regularly reviewed and monitored
through infection prevention meetings.
Issues raised from the Environmental Cleanliness Audit in 2013 were in relation to
décor these have been addressed as part of The Yorkshire Clinics refurbishment
programme for 2013/2014. A new Patient Registration Desk has been built within the
Outpatient Department and all Consulting Rooms have been redecorated and
upgraded during the year. Refurbishment of patient rooms on Ward 1 has now been
completed evidencing a general upgrade in facilities and the introduction of a clinical
hand wash sink in patient rooms to improve infection prevention at The Yorkshire
Clinic
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 Yorkshire Clinic, providing us with a
patient’s eye view of the buildings, facilities and food we offer, giving us a clear
picture of how the people who use our hospital see it and how it can be improved.
The main purpose of a PLACE assessment is to get the patient view.
During 2014/15 The Yorkshire Clinic will take part in Patient Led Assessment of the
Care Environment (PLACE) which builds on the foundation of The Patient
Environment Action Team (PEAT) assessments, with two main differences:
Patients make up at least 50% of the assessment team giving patients
a much stronger voice.
Focus is on improvement with hospitals required to report publicly and
say how they plan to improve.
The PLACE audit for 2014 was undertaken on the 28th April 2014 and submitted for
inspection to the Health and Social Care Information Centre. The results will be
available at the end of June 2014.
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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.
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. All relevant CAS alerts which require action are
reviewed and discussed through Risk, Clinical Governance and medical advisory
meetings.
The Yorkshire Clinic have an occupational health nurse on site who is linked to the
wellbeing programme ensuring robust reporting and awareness is maintained. All
staff members have recently instigated a wellbeing health surveillance programme;
which is directly accessed through the Riskman reporting system. All staff members
have individual logins to ensure privacy and data protection is maintained.
Reporting and learning from clinical incidents
Ramsay Healthcare has introduced electronic incident reporting using a system
known as Riskman. This system is accessible by all members of staff and provides
one tool for the reporting of all incidents, clinical and non-clinical. The implementation
of this tool has enabled the hospital to share incidents and ensure that there is
effective learning and action plans implemented to improve practice as required.
The Yorkshire Clinic has a mandatory training programme which is completed on a
yearly basis by all staff members. The training incorporates:
Customer Care
PREVENT Training
Basic Life Support
Data Protection
Infection Control
Manual Handling
The training sessions are split between clinical and non-clinical allowing a more
detailed approach.
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Mandatory on line e-learning training is also completed on an annual basis by all staff
members who are reviewed and discussed in staff professional development reviews
which are instigated yearly with six month reviews to ensure learning and
development is on-going.
The recent hospital refurbishment has improved upon patient facilities which have
had a positive impact on patient care. The hospital has refurbished all patient rooms
on ward one with an additional eight new premium care rooms. The refurbishment
has included additional hand wash basins in individual patient rooms to improve
infection prevention, carpeting, storage facilities and décor to patient rooms and the
ward corridors with additional lighting. A second refurbishment phase is currently
under review regarding a covered drop off/pick up point for patients, a newly
refurbished reception area to include a larger patient waiting area and coffee/tea
facilities.
A comprehensive Health, Safety and Facilities audit was carried out at the Yorkshire
Clinic by the Ramsay group Estates Manager on the 29th January 2014.
This audit returned a score of 94%. This shows a slight drop from the previous audit
which scored 97% compliance in 2012. This is mainly due to the audit having been
modified and now being more specific in its criteria than previous audits. The results
were passed to the Group Risk Manager prior to his upcoming visit this year.
The Yorkshire Clinic are currently installing a new Liquid Oxygen tank increasing
oxygen capacity for the hospital due to increased activity levels.
In April 2013 the Yorkshire Clinic were successfully recertified for compliance with
Information security ISO 27001 Compliance following an in-depth audit. ISO27001 is
the international standard describing best practice for an Information Security
Management. There were some minor non-conformities and several observations for
improvements including further increasing of awareness amongst staff and changes
to the layout and security of some of the internal rooms.
3.3 Clinical effectiveness
The Yorkshire Clinic 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.
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3.3.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. As demonstrated in the graph below, Ramsay’s rate of return
to theatre has reduced significantly; consistent with our track record of successful
clinical outcomes.
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
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further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
3.4.1 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 48hours of receiving them so that a response can be made to the
patient as soon as possible. As can be seen in the graph below our Patient
Satisfaction rate has increased over the last year.
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The Yorkshire Clinic asks all patients to complete a ‘We Value Your Opinion’ leaflet
to enable us to collate patient opinion and act immediately upon any concerns.
As a direct result of the comments received from the ‘We Value Your Opinion’
questionnaires the following are some examples of how we have improved care:
Our Customer Services Manager and Chefs regularly visit patients following
admission to discuss and receive feedback on the quality of food and the
options available. The catering team work closely with the ward hostess team
to ensure a consistent service is delivered to a high standard.
Catering facilities refurbishment has taken place; including replacement of
some equipment, both in the main kitchen area and the ward serveries.
An additional upgrade of some kitchen equipment and full replacement of
patient crockery and patient bedside water jugs has been actioned.
A full review of menu choice has been reviewed which is to be launched midApril 2014. The new menu offers a greater choice to patients in addition to this
the new options will be listed on an updated menu card.
Additional parking has been sourced off site for members of staff giving extra
car parking spaces for our patients.
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3.5 Hospital Case Study
In 2013 a full review of the ophthalmology services was undertaken at the Yorkshire
Clinic. Whilst the Yorkshire Clinic offered a cataract service the availability of theatre
sessions for these patients was limited and the need of a dedicated local anaesthetic
operating theatre would allow for an immediate increase in theatre availability to treat
a greater number of patients. Patients were initially consulted at the Lodge which is a
satellite facility directly opposite the Yorkshire Clinic. The patient’s surgery was then
undertaken at the Yorkshire Clinic; patients were then reviewed as outpatients once
again at the Lodge. The review highlighted the need for a purpose built site offering a
specialist centre for ophthalmology services under one roof. A business case was
submitted and approved to expand the Yorkshire Clinics current services by enabling
patients to undergo more complex procedures at the centre, which will include the
treatment of patients with posterior capsule opacification, chronic disease and Retinal
Management. This development will also provide access to clinicians for patients who
may need immediate attention for example private patients requiring the injection of
Lucentis.
In September 2013, ophthalmic (cataract) surgery was transferred from the Yorkshire
Clinic to the Lodge. This has provided patients with a much smoother patient journey
as they are not admitted to a general ward and therefore do not encounter as many
touch points as in a general hospital pathway. Our ophthalmic patients now receive
all of their care at the Lodge and are routinely discharged home within 2 hours
following their surgery. This transfer of activity has increased capacity for operating
sessions within ophthalmology for both new and existing consultants who could not
be accommodated on the main hospital site. It is also important to note that the
Lodge is on one level with parking facilities available immediately outside the
premises. We have had positive feedback from patients regarding this new service as
the treatment they receive is offered in one facility with a streamlined consistent
approach.
The Lodge currently has five consultant ophthalmic surgeons who have regular
outpatient and theatre sessions. These consultants offer differing expertise and
special interests which enhance both the retinal and disease management service
thus enabling the Lodge to be considered as a specialist ophthalmology centre.
The Lodge has undergone a recent refurbishment development programme,
incorporating a newly refurbished private waiting area, new equipment and an
additional clinical laser treatment room and consulting room. The laser service
commenced in March 2014. Patients who are experiencing clouding of the lens
following surgery and require corrective laser intervention are offered this service as
an outpatient procedure.
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Appendix 1
Services covered by this quality account
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








Anaesthetics
Audiology
Bariatrics
Cardiology
Cosmetic
Dermatology
Dietetics
Endocrinology
ENT
Gastroenterology
General Medicine
General Surgery
Gynaecology
Haematology
Hand surgery
Nephrology
Neurology
Neurophysiology
Oncology
Ophthalmology
Oral Surgery / Restorative Dentistry
Oral and Maxillo Facial
Orthopaedics
Orthotics
Paediatrics
Pain Management
Pathology
Psychology
Radiology
Respiratory Medicine
Rheumatology
Sleep Studies
Speech Therapy
Urology
Vascular
Venerology
Quality Accounts 2013/14
Page 60 of 62
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
Page 61 of 62
The Yorkshire Clinic
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:
Hospital phone number
01274 550600
www.theyorkshireclinic.co.uk
Quality Accounts 2013/14
Page 62 of 62