QUALITY ACCOUNTS
2013/2014
NO REPORTED MRSA BACTERAEMIA IN THE PAST 5 YEARS
Quality Accounts 2013/14
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Contents
Introduction Page
Welcome to Ramsay Health Care UK and The Westbourne Centre
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2012/13 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
Quality Accounts 2013/14
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Welcome to Ramsay Health Care UK
The Westbourne Centre 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 Westbourne Centre’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our achievements in terms of
clinical excellence, effectiveness, safety and patient experience and demonstrates that our
managers, clinicians and staff are all committed to providing continuous, evidence based, quality
care to those people we treat. It will also show that we regularly scrutinise every service we
provide with a view to improving it and ensuring that our patient’s treatment outcomes are the best
they can be. It will give a balanced view of what we are good at and what we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and summarised and
reviewed quality activities across every hospital and treatment centre within the Ramsay Health
Care UK. It was recognised that this didn’t provide enough in depth information for the public and
commissioners about the quality of services within each individual hospital and how this relates to
the local community it serves. Therefore, each site within the Ramsay Group now develops its
own Quality Account, which includes some Group wide initiatives, but also describes the many
excellent local achievements and quality plans that we would like to share.
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Part 1
1.1 Statement on quality from the General Manager
Sarah Rush
General Manager,
The Westbourne Centre
As the General Manager of The Westbourne Centre I am passionate about ensuring that we
deliver consistently high standards of care to all of our patients.
Our Vision;
“As a committed team of professional individuals we aim to maintain high standards of services
with patient care remaining our focus for everything we do.”
The Westbourne Centre has been established for 5 years. We offer a range of services to private
and NHS patients, ensuring that patient care is at the centre of what we do. This is delivered
through a commitment to teamwork and professionalism between all parties.
Our Quality Accounts details the actions that we have taken over the past year in order to ensure
that our high standards in delivering patient care are maintained and for those areas where we
have identified where we can improve, we have implemented changes to our processes in order to
be able to deliver the required improvements to the delivery of our patient care.
Our Quality Account has been produced to provide information about how we monitor and
evaluate the quality of the services that we deliver throughout The Westbourne Centre. We hope
to be able to share with the reader our progressive achievements that have taken place over the
past year. The Westbourne Centre has a very strong track record as a safe and responsible
provider of Day Case services and we are proud to share our results.
At The Westbourne Centre we believe that each member of staff plays a part in the success of the
unit. We have a training and education plan which involves all members of our administrative and
clinical teams.
Our Quality Accounts have been developed with the involvement of our staff who have very much
involved with developing a systems approach to risk management which focuses on making every
effort to reduce the likelihood and consequence of an adverse event or outcome associated with
treatment of a patient.
To ensure a coordinated approach to the delivery of care for patients and to monitor the
adherence to professional standards and legislative requirements the Clinical Effectiveness
Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and
safety performance of The Westbourne Centre. These committees have reviewed and commented
on the details within these Quality Accounts.
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The quality accounts give all parties and providers access to quality activities and patient
treatment outcomes at The Westbourne Centre. If you would like to comment or provide me with
feedback then please feel free to contact me on the following number or via email;
0121 456 0880 or E-mail sarah.rush@westbournecentre.com
Sarah Rush
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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.
Sarah Rush
General Manager
The Westbourne Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Fazel Fatah - MAC Chair
Mr Hiroshi Nishikawa- Clinical Effectiveness Committee Chair
Mr James Beech – Regional Director Ramsay Health Care UK
Coordinating NHS Commissioners – Dudley CCG
The management team at The Westbourne Centre work in partnership with the MAC and the CEC
ensuring high quality patient care is at the centre of what we do. Regular meetings with the above
committees ensure best practice and sharing of results.
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Welcome to The Westbourne Centre
The Westbourne Centre is a day case hospital in the heart of the Edgbaston Medical Quarter in
Birmingham. We provide fast, convenient, effective and high quality treatment for patients whether
self-funding, medically insured or from the NHS. We accept private patients from the age of 3 and
NHS patients over the age of 18.
All of our theatre cases are performed under local anaesthetic with or without sedation, which
enables patients to be discharged on the same day. (We do not have the facilities for general
anaesthesia so any patients requiring general anaesthetic are transferred to our sister hospital, the
West Midlands Hospital, in Halesowen).
Our specialities include:

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Cosmetic and plastic reconstructive surgery
Restorative dentistry
Oral and maxillofacial surgery
Endodontics and orthodontics
Ophthalmic surgery
Orthopaedic surgery
Ear, nose and throat surgery
General and vascular surgery
Non-surgical and beauty treatments
The Westbourne Centre is centrally located with free on-site parking and is easily accessible via
public transport. We also have disabled access throughout the Centre.
Currently we employ a total of 18 contracted staff and this includes a mix of qualified nurses,
HCAs, administration staff and receptionists. We are supported by a well qualified and
experienced bank team.
All Consultants undergo rigorous vetting procedures, ensuring only those who are qualified and
experienced are granted practicing privileges. The hospital is strictly regulated and audited by the
Care Quality Commission, the governing body responsible for maintaining standards in healthcare,
and the latest report can be found at www.cqc.org.uk.
For the period March 2013 to April 2014 the total number of patients treated was 958, of which 459
(48%) were NHS and 499 (52%) were private.
We offer direct referral services for self pay and insured patients.
All patients requiring NHS services are referred via their General Practitioner, or other primary care
providers (such as Optometrists and Dentists) directly to the hospital, either by Choose and Book
or paper referral.
We work closely with our commissioning CCG at Dudley to provide a range of surgical services
under the NHS Standard Contract via the Choose and Book system.
We also provide orthopaedic and general surgery outreach clinics in the local community.
Quality Accounts 2013/14
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We hold educational sessions with local GP practices and other primary care referrers, with the
help of our consultant body and clinical staff, and provide workshops for practice staff to support
and assist them with the referral processes.
Additional services
The Westbourne Centre has access to Cavendish Imaging, an independent company based at the
Centre. Cavendish Imaging provides a specialist imaging service (x-ray and CT scans) for the
dental, oral and maxillofacial, facial, plastic and ENT surgeons as well as orthodontists.
We also have a physiotherapist who provides treatment for post operative NHS patients and selffunding patients.
Involvement in the community
The Westbourne Centre is proud to support local charities and this year our nominated charity is
the Edward’s Trust, a Birmingham based organisation that provides a wide range of support
services to bereaved families and children.
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Part 2
2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, The Westbourne Centre 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
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 who experience our services.
To achieve these aims, we have various initiatives underway which remain ongoing as we are
consistent in our approach.
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.
Quality Accounts 2013/14
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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 – this project has been fully completed and
introduced this year, as proposed. All patients admitted to The Westbourne Centre for a
procedure, wear their own individually printed, bar coded wristband.

Cleanliness –Infection prevention and control audits continued as planned and local action
plans developed as necessary to ensure the standards are met. The PEAT (Patient
Environment Action Team) was also repeated and we scored 97% overall . The scores
remain above the nationally published average. The PEAT audit has now been replaced
with the PLACE audit. This will be published for the first time in 2014

Investment in day surgery facilities– This project is on-going at The Westbourne Centre
and we have continued to improve the pathway for Day case patients as part of the national
project to offer the most efficient and effective patient journey.
 Falls - Any slips, trips and falls for all staff and visitors were reported through the central
risk management reporting network. The Westbourne Centre is monitored centrally and
reviewed following any incidents. In addition to this any patient falls are reported to the
Health and Safety management group where they are collated and reviewed before being
reported to the Clinical Effectiveness Committee.

‘Never Events’ are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented.
For further details see:
http://www.nrls.npsa.nhs.uk/resources/collections/never-events/
From the list of core never events, there are 3 that could affect The Westbourne Centre:

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
Wrong site surgery
Retained instrument post-operation
Intravenous administration of mis-selected concentrated potassium chloride
The Westbourne Centre have put preventative measures in place and there have not been
any ‘Never Events’ reported in 2013/14
 Acute Care Competencies / Vulnerable Adult training – All staff at The Westbourne
Centre have access and training in the protection of Vulnerable Adults. Ensuring safe
competent staff are available to care for patients continued to be a high priority through
2013/14.
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2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient safety/ experience / clinical effectiveness

RISKMAN
In 2014/15 the new incident reporting system will be continued which will allow greater accuracy in
recording incidents and will also support enhanced data and trend analysis. This will support our
patient safety ethos. Ramsay Health Care UK are constantly looking at ways that risk and
reporting incidents can be managed in an easier and more effective way.
RISKMAN is a software reporting tool already in use in Ramsay Australia that is designed to allow
all staff to log incidents directly into the system as they occur. This allows real time reporting and
better ownership of incidents as it also allows those individual staff members to view the progress
and outcome of any incidents reported.
RISKMAN is our reporting tool for compliments and complaints and for any clinical incidents that
we report both internally, centrally and nationally, for example the numbers of re-operations we
perform, the numbers of readmissions of patients, deaths, infections and transfers of patients to
other hospitals.
Prior to RISKMAN all of these reports were generated and reported via different reporting tools.
New for 2014/2015 is the ability to enter our risk assessments onto RISKMAN, enabling a more
effective management and control of risks. Our aim is to have all risks transferred from our existing
hard drive store to RISKMAN in the next 6 months.

Infection Control
The Westbourne centre is proud of its minimal infection rates and high percentage infection control
audit results. Audits are undertaken in many areas of infection control including hand hygiene and
surgical site.
Our aim for 2014/2015 is the continuation of our high standards by close monitoring of our patient
outcomes and maintaining our excellent infection control measures.
We routinely achieve 100% results in the audits and aim to maintain this high standard in the
coming year.

Reducing the risk of developing thrombosis
VTE (formation of thrombosis following surgery) is still very high on the agenda because of the
risks to health and outcomes following surgery. For that reason we continue to strive to improve
reporting data and compliance to all patients at risk and to those undergoing sedation.
Through careful pre assessment and risk assessment we can reassure our patients that their wellbeing is our priority.
Patients are also empowered to reduce those risks by information given to them at pre
assessment and by preventive treatment e.g. early mobilisation and the use of specific
compression anti-embolism stockings.
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
PROMS
We monitor the national PROMs results for Hernia and varicose vein surgery by offering all
patients who undergo this type of surgery the opportunity to complete a questionnaire before and
after surgery to monitor an improvement in their quality of life.
Encouraging their use identifies poor outcomes and allows us to review practice where necessary.
 Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295

PLACE
April 2013 saw the introduction of PLACE, which is the new system for assessing the quality of the
patient environment, replacing the old Patient Environment Action Team (PEAT) inspections. The
assessments apply to hospitals, hospices and day treatment centres providing NHS funded care.
We will be carrying out this audit and publishing for the first time, in 2014.
PLACE will see our patients be a part of the team in assessing how the environment supports
patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses
entirely on the care environment and does not cover clinical care provision or how well staff are
carrying out their job.
These assessments will take place every year and results will be reported publicly to help drive
improvements in the care environment. The results will show how all hospitals are performing
nationally and locally.

Patient Satisfaction Surveys
Surveys carried out by our external research company show that our patients are 100% satisfied,
relating to the question asked” please give your overall opinion of the quality of your care”.
Although we score high in areas relating to staffing, cleanliness and treating our patients with
dignity and respect, we still have areas where we can improve and these include giving patients
enough information about their medication prior to discharge including any potential side effects.
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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 Westbourne Centre provided and subcontracted 10 NHS services.
The Westbourne Centre has reviewed all the data available to them on the quality of care in all 10
NHS services provided.
The income generated by the NHS services reviewed in 1 April 2013 to 31 st March 14 represents
100% per cent of the total income generated from the provision of NHS services by The
Westbourne Centre for 1 April 2013 to 31st March 14.
Ramsay uses a balanced scorecard approach to give an overview of audit results across the
critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year.
The scorecard is reviewed each quarter by the hospitals senior managers together with Regional
and Corporate Senior Managers and Directors. The balanced scorecard approach has been an
extremely successful tool in helping us benchmark against other hospitals and identifying key
areas for improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient safety and quality
were:
Human Resources
Staff cost % Net Revenue
Agency cost as % of Total staff cost
% Staff Turnover
-31.7%
-0%
- 27% (all due to further advancement in careers)
% Sickness
Appraisal %
Mandatory Training %
Number of Significant Staff Injuries
- 0.46%
- 100%
- 90%
-0
Patient
Formal Complaints per 1000 admissions -5
Patient Satisfaction Score
-100%
Number of Significant Clinical Events per 1000 admissions - 4
Readmission per 1000 Admissions
-2
Quality
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
- 98%
- 100%
- 78%
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2.2.2 Participation in clinical audit
The national clinical audits and national confidential enquiries that The Westbourne Centre was
eligible to participate in during 1 April 2013 to 31st March 2014 are as follows:
 Elective procedures
Elective surgery (National PROMs Programme)
The national clinical audits and national confidential enquiries that The Westbourne Centre
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.
National Clinical Audits
Name of Audit
Participation
% cases
submitted
Elective surgery (National PROMs Programme)
Yes
99%

Although 99% of the eligible cases admitted participated in the initial part of the survey, there
were less than the minimum number of required post operative surveys to reach the threshold
required to gain an average score. Consequently we are unable to comment on any health
gain score as this figure is not published nationally.
The report of the national clinical audit from 1 April 2013 to 31st March 2014 was reviewed by the
Clinical Governance Committee and The Westbourne Centre intends to take the following action
to improve the quality of healthcare provided:

The target for 2014 / 2015 will be for 100% cases to be submitted
Local Audits
There is a robust local Clinical Audit programme in place. Throughout the year 64 audits were
undertaken. These included infection prevention and control, dental decontamination, theatre and
dental radiology. The audit results are reviewed both nationally and at a local level by the Clinical
Governance Committee. The clinical audit schedule can be found in Appendix 2.
The Westbourne Centre intends to take the following actions to improve the quality of healthcare
provided.
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-Surgical safety checklist Audit
This audit is carried out quarterly and our average score was 97%
Our aim for 2014/2015 is to achieve 100%
This target will be achieved by ensuring the WHO surgical checklist is completed in full for all
patients
-Care of the deteriorating patient
This audit is carried out Bi annually and our average score was 76%
Our aim for 2014/2015 is to achieve 95%
Following some updated training we are now in the process of following procedure for post
operative care regarding the care plan pathway and have started to score assess the patients. Up
until now and the explanation for the low score, all observations were recorded on the post
operative chart. They are now being recorded on the specific Early Warning Score document form
and this will reflect in the score for the next audit.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 to participate in research approved by a research
ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning
for Quality and Innovation) Framework
A proportion of The Westbourne Centre’s income from 1 April 2013 to 31st March 2014 was
conditional on achieving Quality Improvement and Innovation goals agreed between them 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.
CQUINS for 2013/2014
VTE Risk assessment
VTE Root cause analysis
Patient safety culture
Patient experience for learning disabilities
CQUINS for 2014/2015
Friends and Family test ( Staff and patients)
Culture of learning
Patient safety culture
Obesity management
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2.2.5 Statements from the Care Quality Commission (CQC)
The Westbourne Centre is required to register with the Care Quality Commission and its current
registration status on 31st March 2014, is registered without conditions.
The Westbourne Centre has not participated in any special reviews or investigations by the CQC
during the reporting period.
2.2.6 Data Quality
The Westbourne Centre submits both national and quality data at required reporting periods.
Examples include:
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Mixed sex breaches
Duty of candour
Preventing people dying prematurely ( recording of smoking status)
Ensuring people have a positive experience of care ( patient questionnaires)
We consistently achieve 100% in most of our quality measures and aim to continue this for
2014/2015
NHS Number and General Medical Practice Code Validity
The Westbourne Centre 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:
99.97% for admitted patient care;
99.96% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
100% for admitted patient care;
100% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score for 2013/2014
was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate
The Westbourne Centre was not subject to the Payment by Results clinical coding audit during
2013/14 by the Audit Commission.
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2.2.7 Stakeholders views on 2013/14 Quality Account
Dudley CCG as Lead Coordinating Commissioners have had the opportunity to review this
document and any feedback has now been added.
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Fiona Brown Clinical Lead
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay Quality
Accounts. Through each year, month on month, we analyse our performance on many levels, we
reflect on the valuable feedback we receive from our patients about the outcomes of their
treatment and also reflect on professional opinion received from our doctors, our clinical staff,
regulators and commissioners. We listen where concerns or suggestions have been raised and, in
this account, we have set out our track record as well as our plan for more improvements in the
coming year. This is a discipline we vigorously support, always driving this cycle of continuous
improvement in our hospitals and addressing public concern about standards in healthcare, be
these about our commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open
and honest where outcomes and experience fail to meet patient expectation so we take action,
learn, improve and implement the change and deliver great care and optimum experience for our
patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working which assure
that the quality of patient care is central to the business of the organisation.
The emphasis is on providing an environment and culture to support continuous clinical quality
improvement so that patients receive safe and effective care, clinicians are enabled to provide that
care and the organisation can satisfy itself that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance systems in the
organisation and should not be seen as a “stand-alone” activity. All 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.
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In developing this framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of
all the necessary strategies, policies, systems and processes for effective Clinical Governance.
The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
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National guidance
Ramsay also complies with the recommendations contained in technology appraisals issued by
the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by the
NHS Commissioning Board Special Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that
are applicable to our business and thereafter monitoring their implementation.
3.1 The Core Quality Account indicators
Expected
deaths:
Period
Apr12 Mar13
Jul12 Jun13
Best
Worst
Average
Period
Westbourne
RBA
0.1
RWH
44.0
Eng
20.4
2012/13
NVC44
0.0
RBA
0.0
RWH
44.1
Eng
20.2
2013/14
NVC44
0.0
The Westbourne Centre considers that this data is as described for the following reason:
There were no expected deaths as we do not have patients requiring palliative or long term care.
PROMS:
Hernia
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT415
0.157
NVC27
0.015
Eng
0.085
RTG
0.138
RNA
0.019
Eng
0.086
Period
Apr12 Mar13
Apr13 Sep13
Westbourne
NVC44
n/a
NVC44
n/a
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre did not have sufficient numbers of patients taking part in this audit to be
included in the %s
The Westbourne Centre has taken the following action to improve this number and so the quality
of its services:By an increase in the relevant services available through the introduction of satellite clinics
Quality Accounts 2013/14
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PROMS:
Veins
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
RV8
5.14
NT350
-15.92
Eng
-8.374
RTD
-9.74
RLN
-10.52
Eng
-9.46
Period
Apr12 Mar13
Apr13 Sep13
Westbourne
NVC44
NVC44
n/a
n/a
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre did not have sufficient numbers of patients taking part in this audit to be
included in the %s
The Westbourne Centre has taken the following action to improve this number and so the quality
of its services:By an increase in the relevant services available through the introduction of satellite clinics
PROMS:
Hips
Period
Apr12 Mar13
Apr13 Sep13
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
Westbourne
NVC44
n/a
NVC44
n/a
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre do not undertake this type of procedure.
PROMS:
Knees
Period
Apr12 Mar13
Apr13 Sep13
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
Westbourne
NVC44
n/a
NVC44
n/a
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre do not undertake this type of procedure.
Readmissions:
Period
Best
Worst
Average
Period
Westbourne
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2012/13
NVC44
0
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
2013/14
NVC44
0
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre has had no NHS readmissions. It is a day case hospital and the type of
procedures carried out, would rarely warrant a readmission.
Quality Accounts 2013/14
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Responsiveness
Period
Best
Worst
Average
Period
Westbourne
to personal
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC44
n/a
needs
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC44
n/a
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre is a day case hospital and so this indicator will not apply
VTE
Assessment:
Period
Best
Worst
Average
Period
Westbourne
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q3
NVC44
100.0%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
13/14 Q4
NVC44
100.0%
The Westbourne Centre considers that this data is as described for the following reasons:
The Westbourne Centre carry out an assessment on all admissions and record the data
appropriately. This indicator is also monitored internally, through the monthly audit programme.
C. Diff rate:
Period
Best
Worst
Average
Period
Westbourne
per 100,000
2012/13
Several
0
RNA
58.2
Eng
22.2
2012/13
NVC44
0.0
bed days
2013/14
Several
0
RVW
30.8
Eng
17.3
2013/14
NVC44
0.0
The Westbourne Centre considers that this data is as described for the following reason:
The Westbourne Centre has no cases to report. It is a day case hospital and patients are unlikely
to contact C.Diff during such a short hospital stay.
Incident Rate:
Period
Best
Worst
Average
Period
Westbourne
Patient Safety
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
NVC44
0.83
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
2013/14
NVC44
4.1
The Westbourne Centre considers that this data is as described for the following reasons:
- An increase in figures for the period 2012/13 is due to a significant increase in patient admissions
over the previous period, 2011/2012
- A new system of reporting incidents, “Riskman”, has created a more transparent way for staff to
report and this may be another reason for increase in numbers
The Westbourne Centre has taken the following action to improve this percentage and so the
quality of its services:-
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- Policy and protocol review and training
- Review of risk assessments
- Continued audit of patient safety
SUIs:
(Severity 1 only)
Period
Best
Jul - Sep 12
Oct11 Sep12
Worst
Average
NA
NA
NA
NA
NA
Eng
11,563
Period
Westbourne
2012/13
NVC44
0.0%
2013/14
NVC44
0.0%
The Westbourne Centre considers that this data is as described for the following reason:-There have been no serious incidents at The Westbourne Centre recorded on “Riskman”. This
open system of reporting incidents is closely monitored and reported on by the Ramsay Corporate
team at Head Office and results shared and nationally.
F&F Test:
Period
Jan-14
Feb-14
Best
Several 100
Several 100
Worst
RPA02
RPA02
27
18
Average
Eng
73
Eng
73
Period
2012/13
2013/14
Westbourne
NVC44
n/a
NVC44
n/a
The Westbourne Centre considers that this data is as described for the following reason:-The Westbourne Centre take part in the F&F test but the numbers are not included in the national
average as we are a day case hospital only. We routinely achieve 100% success on the figures
that are submitted.
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every year and in all
performance respects, and certainly in regards to our track record for patient safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more routinely from
tracking trends in performance indicators.
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3.2.1 Infection prevention and control
The Westbourne Centre has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 5 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia
and Clostridium Difficile infections with a programme to minimise potential incidents year on year.
Infection Prevention and Control management is very active within our hospital. An annual
strategy is developed by a corporate level Infection Prevention and Control (IPC) Committee and
group policy is revised and re-deployed every two years. Our IPC programmes are designed to
bring about improvements in performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the Ramsay
organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:

Link personnel from The West Midlands Hospital support our own lead IC nurse at The
Westbourne Centre and we have links with our local NHS Trust Microbiologist and local
NHS Trust Infection Control Nurses.

E-Learning and Mandatory training sessions held for all clinical staff.

Actively involving the infection control nurse in working in the clinical environments to audit
and advise staff members and consultants in infection control issues including hand
hygiene.

Our lead Infection control nurse advises staff on reporting mechanisms for infections
/wound problems using examples of reporting tools and policies available.
A graph cannot demonstrate the extremely low HCAI rate of 0.001% for 2013/2014.
The Westbourne Centre is proud of the low figure and will aim to continue with such vigilance in
monitoring and auditing infection control, in the forthcoming year.
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 within the Ramsay group and The Westbourne Centre will
be elligible to take part for the first time this year .It provides us with a patient’s eye view of the
buildings, facilities and food we offer, giving us a clear picture of how the people who use our
hospital see it and how it can be improved.
The main purpose of a PLACE assessment is to get the patient view.
We look forward to displaying our results in next year’s Quality Report.
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3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around
sharps and needles.
As a result, ensuring our staff have high awareness of safety has been a foundation for our overall
risk management programme and this awareness then naturally extends to safeguarding patient
safety.
Our record in workplace safety as illustrated by accidents per 1000 admissions demonstrates the
results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in healthcare.
Multiple updates relating to drugs and equipment are received every month and these are sent in
a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety
alerts, medicine / device recalls and new and revised policies are cascaded in this way to our
General Manager which ensures we keep up to date with all safety issues.

All staff are actively encouraged to report incidents as by doing this we can identify areas
for improvement. All incidents are then reviewed by the Health and Safety Team, root
cause analysis is carried out and any trend and or recommendation is acted upon. They are
also reported into the central reporting tool, “RISKMAN”, to ensure trends and key issues
are highlighted group wide and lessons shared/actions taken across the company where
necessary in a timely and structured fashion.
 All incidents that are reported on are divided into subsections separating clinical from nonclinical, with clinical incidents coming under the umbrella of clinical effectiveness.
 Annual risk assessment audits maintain up to date and effective safe practice within the
Centre
3.3 Clinical effectiveness
The Westbourne Centre has a Clinical Governance team that meet regularly through the year to
monitor quality and effectiveness of care. Clinical incidents, patient and staff feedback are
systematically reviewed to determine any trend that requires further analysis or investigation. More
importantly, recommendations for action and improvement are presented to hospital management
and medical advisory committees to ensure results are visible and tied into actions required by the
organisation as a whole.
3.3.1 Return to theatre
The Westbourne centre is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary treatment is an
important measure. Every surgical intervention carries a risk of complication so some incidence of
returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. Ramsay’s rate of return is very low and consistent with our track record of
successful clinical outcomes.
The Westbourne Centre has a zero return to theatre rate for 2013/2014.
.
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3.4 Patient experience
All feedback from patients regarding their experiences with The Westbourne Centre 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 fed back 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 fed back via the various methods below, and are regular agenda items on
Local Governance Committees and at Head of department meetings for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay Corporate and
Dept of Health 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
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3.4.1 Patient Satisfaction Surveys put in graphs
Our patient satisfaction surveys are managed by a third party company called ‘Qa Research’. This
is to ensure our results are managed completely independently of the hospital so we receive a true
reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call following their
discharge from the hospital. The results from the questions asked are used to influence the way
the hospital seeks to improve its services. Any text comments made by patients on their survey
are sent as ‘hot alerts’ to the Hospital Manager within 48hrs of receiving them so that a response
can be made to the patient as soon as possible.

As can be seen in the above graph our patients are 100% satisfied. This relates to the
questions asked” please give your overall opinion of the quality of your care” and “How likely
are you to refer your friends and family to the hospital”.

Although we score high in areas relating to staffing, cleanliness and treating our patients with
dignity and respect, we still have areas where we can improve and these include giving
patients enough information about their medication prior to discharge including any potential
side effects.
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3.5 The Westbourne Centre Case Study
The Westbourne Centre prides itself in working closely with consultants to ensure patients are
offered the latest advances in medical technology. During 2013/2014 we have looked at further
developing the range of treatments and services for self paying, insured and NHS patients.
One such area we have looked at during this period is providing NHS services at a satellite unit.
This has involved close working relationships with GP’s at a local surgery.
This service has been established to assist the patients with choice over locality of their initial
appointments and facilitate the choose and book scheme, not only for patients attached to that
particular surgery, but for all those in the locality. Patients can now choose to attend either The
Westbourne Centre for their initial Consultation or their local GP practice.
Our consultants were also key in ensuring that we developed the service and were involved in the
decisions regarding choice of satellite venue.
Our intention is to build on this service over 2014/15, widening further and developing the services
available.
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Appendix 1
Services covered by this quality account
Treatment of Disease, Disorder or Injury
Lasers for - Hair Reduction
- Vascular/Pigmented Lesions
- Laser Eye Surgery
Shockwave Therapy
Ambulatory and day surgery
Surgical Procedures
Diagnostic
All surgical Treatments under LA/ Sedation
-
Dental implants
Minor oral/periodontal surgery
Cosmetic
Dermatological
General Surgery
Ophthalmic
Minor Orthopaedic
ENT
-
Phlebotomy
Specimen collection
Histology
-
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each
month
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Appendix 3
Abbreviations
HCA - Health care assistant
CCG – Clinical commissioning Group
CT scan – Computerised tomography scan
VTE – Venous Thromboembolism
PROMS – Patient reported outcome measures
PLACE – Patient led assessments of the care environment
CQUIN – Commissioning for quality and innovation
MRSA – methicillin- resistant staphylococcus aureus
HCAI – Healthcare associated infection
MAC – Medical advisory committee
CEC – Clinical effectiveness committee
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THE WESTBOURNE CENTRE
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:
0121 456 0880
www.westbournecentre.com
Neurological Centres
Quality Accounts 2013/14
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