Winfield Hospital
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2010/11 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
Patient Feedback
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Winfield Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group, was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, Clinical Commissioning
Groups.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring
that high quality patient care is our number one goal. This relies not only on
excellent medical and clinical leadership in our hospitals but also upon an
organisation wide commitment to drive year on year improvement in patient
satisfaction and clinical outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is not
about reliance on one person or a small group of people to be responsible and
accountable for our performance. It is essential that we establish an
organisational culture that puts the patient at the centre of everything we do and
as a long standing and major provider of healthcare services across the world,
Ramsay has a very strong track record as a safe and responsible healthcare
provider and we are proud to share our results.
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every year
we set our targets higher, working on every aspect of our service to bring a
continuing stream of improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2013/14
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Introduction to our Quality Account
This Quality Account is Winfield Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
Quality Accounts 2013/14
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Part 1
1.1 Statement on quality from the General
Manager
Welcome to Winfield Hospital’s quality account, which I hope you will find both
interesting and informative. This report outlines the Hospital’s approach to quality
improvement, progress made in 2013 - 2014 and plans for the forthcoming year.
Winfield Hospital has five key values which underpin everything we do as an
organisation. They are:
• Put the patient first;
• Work as one team;
• Respect each other;
• Strive for continual improvement;
• Respect environmental sustainability.
The experience that patients have in our hospital is of the utmost importance to
us. As well as being treated safely and quickly, they must receive a personalised
service, enhanced by good communication and a commitment to ensuring their
privacy and dignity are respected at all times.
During 2013-2014 we have made a number of improvements to ensure that
patients in our hospital receive the best possible care.
This report demonstrates that the experience patients have in our hospital, the
quality of the care they receive, and the safety of the service we provide are top
priorities for Winfield Hospital.
In addition, it shows how our values, combined with our priorities, are improving
the way in which we treat our patients.
Richard Foulkes,
General Manager Winfield Hospital
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Richard Foulkes
General Manager
Winfield Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Dr Marion Andrews Evans, Director of Nursing and Quality, Gloucestershire
Clinical Commissioning Group
Mr Rick Majkowski, consultant orthopaedic surgeon – Medical Advisory
Committee Chair
Dr Richard Vanner, consultant anaesthetist - Clinical Governance Committee
Chair
Mr Mike Scott, consultant colo-rectal surgeon, Clinical Governance Committee
Chair and lead consultant for Endoscopy
Stefan Andrejczuk - Regional Director South
Mrs Mandy Keedwell – patient representative
Mr John Roberts – patient representative
‘Thank you for asking me to scrutineer the Quality account for 2013/14.the only
point I would make is that some of the clinical abbreviations may not be clear to the
layman, a glossary of these may help. It is very good to see improvements year on year.
To achieve 100 percent is hard enough but to maintain it is harder. In conclusion I
congratulate you and all the staff for achieving the high standards at all times. Many
thanks for a very good report’
Unfortunately Healthwatch Gloucestershire was unable to make comment on this
document this year.
Quality Accounts 2013/14
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Welcome to Winfield Hospital
Winfield Hospital is an independent hospital located on the outskirts of the city of
Gloucester. It is situated off the Northern Ring Road with excellent road and rail
links.
Consideration for our patients is at the heart of everything that we do. We are
constantly seeking new ways of working and bringing in fresh clinical practices
that will improve outcomes for our patients.
Our approach to service delivery, which currently includes working in partnership
with the NHS, is courteous and professional and we take great pride in our ability
to innovate and look at new ways of working.
Winfield Hospital has three theatres all with ultra clean air technology and a
dedicated endoscopy suite The ward has 39 inpatient beds, 33 of which are
single rooms and 3 doubles, all with en suite facilities. Two of the ward single
rooms are designated High Dependency Beds offering level 2 critical care.
Diagnostic facilities include an imaging department with on site x-ray,
ultrasound, and dental x-ray equipment. MRI and CT scanning services are
supplied by Ramsay UK Diagnostic mobile units
We have a substantial physiotherapy department which has a fully equipped
gymnasium and treatment rooms. Services include Hydrotherapy, Hand Therapy,
Continence /Women’s Health, Sports Injuries, musculoskeletal assessment and
treatment and Post Operative Rehabilitation, Pilates, Back School, Acupuncture,
Phototherapy (UVB for skin conditions),and neurological
rehab(strokes/MS/Parkinson’s)
The Hospital also has a well equipped outpatient department with 11 consulting
rooms and a dedicated minor procedures area.
An onsite pharmacy registered with the Royal Pharmaceutical Society of Great
Britain is also based within the department.
Delivering a full range of specialist surgical and medical services that include
Cardiology, Dermatology, Endoscopy, ENT, General Surgery, Gynaecology,
Plastic Surgery, Ophthalmology, Orthopaedics and Urology, we provide fast,
convenient, effective and high quality treatment for patients of all ages (excluding
children below the age of 18 years for NHS care or 16 years if private).
Our pathology services are provided by Gloucestershire Royal Hospitals NHS
Trust with whom we have a close working relationship for this plus other
specialised clinical services that we are unable to provide in house.
Quality Accounts 2013/14
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At the Winfield Hospital we work closely with our local Clinical Commissioning
Group to provide a range of surgical services under the “Any Qualified Provider”
contract. We also have an excellent relationship with Tetbury Hospital and
support their in-patient choice activity. We employ a GP liaison officer who has
direct involvement with all the local GPs and who actively promotes Winfield as a
Hospital of Choice.
We are committed to delivering services within the community where possible
and actively seek opportunities to provide outreach clinics in rural areas.
In 2013 we treated a total of 5,250 patients. Of these 2,411 were private patients
(46%) and 2839 were NHS patients (54%).
Winfield Hospital has 158 consultants with practising privileges and employs 180
staff, both clinical and non clinical.
The nursing staff to patient ratio on the ward ranges between 1:5 to1:8. This is
calculated taking into account patient dependency but not in isolation. There is an
experienced Residential Medical Officer (RMO) on site 24 hours a day
We offer direct referral services for private Cosmetic Surgery and aesthetic
cosmetic treatments.
All patients requiring NHS services are referred via their General Practitioner
(GP)
We regularly hold patient information evenings on different medical subjects and
have recently held sessions on knee pain and snoring.
As part of the local community, staff at the Winfield Hospital regularly take part in
events in Gloucestershire. A team of staff have taken part in the Race for Life
three years running now and for the second year a team took part at the annual
Dragon Boat Race at Gloucester Docks. Each year staff vote for a local charity for
which to fundraise. This year Sue Ryder was nominated and money has been
raised by staff quiz nights and raffles at the annual barbeque.
The rotary club in Gloucester utilise our car park on Gloucester Rugby Club
match days to raise funds for themselves by charging a small parking fee. This is
very popular with the fans!
Our meeting room is used frequently by local GP practices and medical charities
and the Winfield Hospital is proud to support the local education trust for GP’s
(GGPET) as a venue for their educational workshops and seminars.
Quality Accounts 2013/14
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Winfield Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
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Priorities for improvement
2.1.1 A review of clinical priorities 2013/14 (looking back)
Safer Surgery Checklists
The World Health Organisation (WHO) Surgical Safety Checklist is designed to
reduce the number of errors and complications resulting from surgical procedures
by improving team communication and by verifying and checking essential care
interventions.
At the Winfield Hospital we continually monitor our compliance with the WHO
safer surgery checklists within our theatres. We undertake numerous internal
audits of compliance and these now include pre and post theatre list briefings with
the whole team to ensure a more robust approach.
Any audit scores that have been below the expected 100% during the year were
reviewed by a clinical team within the hospital and lessons learnt fed back to the
relevant staff.
VTE risk assessment
Our aim for 2013 / 14 was to ensure that 100% of all eligible patients admitted to
the Winfield Hospital had a VTE risk assessment prior to surgery. We have
achieved this and continue to assess all admitted patients.
RISKMAN
Ramsay Health Care UK is very diligent about how we manage risk in our
hospitals, treatment centres and workplaces to ensure that safety is paramount
for patients, staff and visitors. Ramsay Health Care UK are constantly looking at
ways that risk and reporting incidents can be managed in an easier and more
effective way. As such they implemented a risk reporting tool already in use in
Australia in the UK.
RISKMAN became our reporting tool for compliments and complaints also last
year and has developed further in 2013 – 14 as a risk register for the hospital and
more recently the implementation of legal reporting through the same medium.
This enables all patient and safety issues to be linked within the same system.
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Meeting endoscopy standards
In February 2014 we achieved JAG accreditation for our endoscopy services.
This is a prestigious achievement and Winfield Hospital is one of only two
hospitals in Gloucestershire to have been awarded this.
The JAG Accreditation Scheme is a patient centred and workforce focused
scheme based on the principle of independent assessment against recognised
standards. The scheme was developed for all endoscopy services and providers
across the UK in the NHS and Independent Sector.
What is JAG Accreditation intended to accomplish?
• Stimulate continuous improvement in processes and patient outcomes
• 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
To achieve full JAG Accreditation an endoscopy service must provide clear
evidence that they have met all of the standards.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient Experience
Patient satisfaction
We continue to ensure that those who use our services have a positive
experience. We monitor this through our patient survey ratings and the national
‘Friends and Family’ test.
Friends and Family responses are another of our quality targets with
Gloucestershire CCG this year with expectations of increased patient response
and satisfaction both in the outpatient and inpatient setting by the end of March
2015.
Further information about Friends and Family testing can be found on the NHS
Choices website:
http://www.nhs.uk/NHSEngland/AboutNHSservices/Pages/nhs-friends-andfamily-test.aspx
Quality Accounts 2013/14
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Patient feedback
We are aware from our patient satisfaction surveys areas of improvement that we
need to make across the coming twelve months. This includes increasing the
number of patients who receive copies of the letter to their GP on discharge. This
is monitored on a monthly basis by quality reports to Gloucestershire CCG and
will continue to be monitored from the patient survey responses we receive.
Although we have very good results from our patient satisfaction survey we are
very aware that these are received from a small proportion of our admitted
patients and across 2013 this was approximately 12.5% of our admitted patients.
Our target for this year is to increase our patient response by ensuring a minimum
of 50% of admitted patients are invited to take part.
An area for improvement from our 2013 patient responses is that all patients
report that they were fully informed of their medication to take home and were
made aware of potential side effects. This is being monitored through the hospital
Clinical Governance Committee (which includes the hospital pharmacy manager)
and Senior Management Team.
Patient safety
Clinical staff training
The safety of our patients is paramount. In addition to our annual training
programme for clinical staff we have commenced specific training plans for
outpatient nursing staff who undertake pre admission of patients and for ward
nursing staff to increase their skills in high dependency nursing. The latter
involves an ongoing rolling programme of secondments to ITU / HDU at the local
Trust.
Robust preadmission of patients is essential and minimises the risk of patients
being cancelled for procedures on the day of admission. Our outpatient nurses
receive training from one of our consultant anaesthetists.
Any surgical procedure cancelled on the day of operation for either clinical or non
clinical reasons is reported to Gloucestershire CCG as part of our monthly
reports,
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Safer Surgery Checklists
As previously stated, the World Health Organisation (WHO) Surgical Safety
Checklist is designed to reduce the number of errors and complications resulting
from surgical procedures by improving team communication and by verifying and
checking essential care interventions.
At the Winfield Hospital we continually monitor our compliance with the WHO
safer surgery checklists within our theatres by use of internal audit.
Compliance with the WHO Surgical Safety Checklist is another of our quality
targets with Gloucestershire CCG and we submit monthly audit scores and
quarterly action plans to them. Ramsay Health Care UK has made a training DVD
for the WHO check which is to be rolled out across the group as best practice
later this year.
Staff satisfaction
Staff satisfaction plays an integral part in the delivery of quality care. Our priority
for 2013 – 14 was to raise the overall response rate and we have achieved this.
Unfortunately our staff satisfaction score showed a down turn and actions have
been put in place to respond.
A staff group has been formed from across the different disciplines in the hospital
and we are expecting an increase across the board by having representation in
this group who are able to express what is required to achieve this.
During the last quarter of this year we will also be running the nationally
mandated Friends and Family staff satisfaction and this too forms part of our
quality initiatives with Gloucestershire CCG.
Further information about the staff Friends and Family test can be found here:
http://www.england.nhs.uk/ourwork/pe/fft/staff-fft/
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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 Winfield Hospital provided and/or subcontracted 18,939 NHS
services.
The Winfield Hospital has reviewed all the data available to them on the quality of
care in 100% of these NHS services.
The income generated by the NHS services reviewed from 1st April 2013 to 31st
March 14 represents 100% per cent of the total income generated from the
provision of NHS services by the Winfield Hospital for 1 April 2013 to 31st March
14
In 2013 we treated a total of 5,250 patients. Of these 2,411 were private patients
(46%) and 2,839 were NHS patients (54%)
Winfield Hospital was subject to the Payment by Results clinical coding audit
during 2013/14 by the Audit Commission.
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.
Quality Accounts 2013/14
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In the period for 2013/14, the indicators on the scorecard which affect patient
safety and quality were:
HUMAN RESOURCES
Staff Costs as % Net Revenue
HCA Hours as % of Total Nursing
Agency Costs as % of Total Clinical Staff Costs
Ward Hours PPD
% Staff Turnover rolling 12 month
% Sickness rolling 12 months
% Lost time (includes annual leave, study leave
and sick leave)
Appraisal %
Staff Satisfaction Score (max possible 7)
Number of Significant Staff Injuries
PATIENT
Formal Complaints per 1000 HPDs
Patient Satisfaction Score
Significant Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
QUALITY
Workplace Health and Safety Score
Infection Control Audit Scores:
Hand hygiene
Environmental audit
Cannulation audit
Mandatory training compliance
27.6
17.2%
0.3%
4.6
13.8%
3.7%
24.4%
82%
3.86
0
0.14
96.4%
1.01
3.01
94%
97.5%
100%
90.5%
91%
63%
Quality Accounts 2013/14
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2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014 Winfield Hospital participated in 100% of
the national clinical audits we were eligible to participate in. We were not eligible
to participate in any of the national confidential enquiries.
The national clinical audits and national confidential enquiries that Winfield
Hospital participated in, and for which data collection was completed during 1
April 2013 to 31st March 2014, are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome
Review Programme
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
% cases
submitted
75%
77%
The reports of two national clinical audits from 1 April 2013 to 31st March 11 2014
were reviewed by the Clinical Governance Committee and Winfield Hospital
intends to take the following actions to improve the quality of healthcare provided.


Improve our internal processes for submitting data to the NJR.
Review and improve how we discuss the importance of PROMS with our
eligible patients as we know that we submit all questionnaires completed
within the hospital.
Local Audits
The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Winfield Hospital intends to
take the following actions to improve the quality of healthcare provided. The
clinical audit schedule can be found in Appendix 2.
All audits showed good compliance and our main priorities for this year are
Nutrition and Hydration and a general improvement in documentation. Both of
these are hot topics this year and form part of our clinical quality monthly reports
to Gloucestershire CCG.
Quality Accounts 2013/14
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2.2.3 Participation in Research
There were no patients recruited during 2012/13 to participate in research
approved by a research ethics committee.
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2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Winfield Hospital income in from 1 April 2013 to 31st March 2014
was conditional on achieving quality improvement and innovation goals agreed
Winfield 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.
All goals for 2013 – 14 were achieved.
Goal
No
1
2
3
4
5
Goal Name
Description of
Goal
Friends and The Friends and Family Test will
Family Test
provide timely, granular feedback
from patients about their
experience. CQUIN goals relate
to phased implementation of
nationally determined FFT and to
demonstrated improvement in
response rate.
NHS Safety 2nd year of national CQUIN
Thermometer which aims to measure 4 key
harm areas: VTE, Pressure
Ulcers, Dementia and Falls.
CQUIN improves data
consistency. Provider currently
has a zero level of harm in all 4
areas.
Venous
To reduce avoidable death,
Thromboembodisability and chronic ill health
lism (VTE)
from VTE. CQUIN goals based
on attainment of 95% risk
assessment for all patients
Goal
Weighting
Quality
Domain
20%
Patient
National
Experience goal
20%
Patient
Safety
National
goal
20%
Patient
Safety
National
goal
Patient
Satisfaction
Survey
Based on the new staff survey
for Ramsay which starts in April
13. Ambitions for 13/14 CQUIN
goal targets will be based upon
Q1 baseline results.
20%
Patient
Local Goal
Experience
WHO Safer
Surgical
Checklist
Compliance with WHO safer
surgical checklists. 90% target
for all day case and inpatient
surgical procedures.
20%
Patient
Safety
Totals:
Local Goal
100.00%
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2.2.5 Statements from the Care Quality Commission (CQC)
Winfield Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions.
Winfield Hospital has not participated in any special reviews or investigations by
the CQC during the reporting period.
2.2.6 Data Quality
Winfield Hospital will be taking the following actions to improve data quality.
Data contained in medical records is audited on a monthly basis and actions are
taken to improve quality within this domain as required.
We have measures in place to improve our registration of patient errors by means
of additional training and monitoring through a number of audit channels.
We regularly use statistical data to monitor clinical services and are constantly
striving to improve this by regular quality control initiatives.
We have a data quality lead who follows up on all reports to ensure that data is
submitted correctly.
NHS Number and General Medical Practice Code Validity
Winfield Hospital submitted records during 2013/14 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which
are included in the latest published data. The percentage of records in the
published data which included:
The patient’s valid NHS number:
 99.97% for admitted patient care;
 99.96 for outpatient care;
 0% for accident and emergency care (not undertaken at our hospital)
The General Medical Practice Code:



100% for admitted patient care;
100% for outpatient care; and
0% for for accident and emergency care (not undertaken at our hospital).
Quality Accounts 2013/14
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Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall
score for 2013/14 was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate.
In October 2013 Winfield Hospital was subject to the Payment by Results clinical
coding audit by the Audit Commission with the following results:




Primary diagnosis – 96% correct
Secondary diagnosis – 94% correct
Primary procedure – 94% correct
Secondary procedure – 97% correct
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2.2.7 Stakeholders views on 2013/14 Quality Account
Sanger House
5220 Valiant Court
Gloucester Business Park
Brockworth
Gloucester
GL3 4FE
30th September 2014
Helen Martin
Matron
Winfield Hospital
Tewkesbury Road
Longford
Gloucester GL2 9WH
Dear Helen
Gloucestershire Clinical Commissioning Group (CCG) has taken the opportunity to review the
Quality Account prepared by Winfield Hospital for 2013/14.
We are pleased that Winfield Hospital has worked alongside the CCG during 2013/14 to maintain
and further improve the quality of commissioned services.
The CCG welcomes Winfield Hospital’s strong focus on patient experience and quality of care,
which demonstrates a joint commitment to delivering high quality compassionate care. The
hospital is to be congratulated on obtaining JAG accreditation.
There are robust arrangements in place with Winfield Hospital to agree, monitor and review the
quality of services. The contract and quality teams meet on a regular basis and bring together
senior clinicians and managers from both Winfield Hospital and Gloucestershire CCG. The CCG
have received assurance throughout the year from Winfield Hospital in relation to key quality
issues and the CQUIN (Commissioning for quality and innovation) schedule, which identifies
specific quality issues, have been achieved.
Gloucestershire CCG can confirm to the best of our knowledge that we consider that the Quality
Account contains accurate information in relation to the quality of services that Winfield Hospital
provides.
Yours sincerely
Dr Marion Andrews Evans
Director of Nursing and Quality
Quality Accounts 2013/14
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Matron, Helen Martin
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our
performance on many levels, we reflect on the valuable feedback we receive from
our patients about the outcomes of their treatment and also reflect on
professional opinion received from our doctors, our clinical staff, regulators and
commissioners. We listen where concerns or suggestions have been raised and,
in this account, we have set out our track record as well as our plan for more
improvements in the coming year. This is a discipline we vigorously support,
always driving this cycle of continuous improvement in our hospitals and
addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe
in being open and honest where outcomes and experience fail to meet patient
expectation so we take action, learn, improve and implement the change and
deliver great care and optimum experience for our patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
Quality Accounts 2013/14
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management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
Quality Accounts 2013/14
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National Guidance
Ramsay Health Care UK 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 Health Care UK 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 indicator
Mortality
Period
Best
Worst
Average
Period
Winfield
2012/13
RKE
0.65
RXL
1.17
Eng
1
2012/13
NVC22
0
2013/14
RKE
0.63
RBT
1.15
Eng
1
2013/14
NVC22
0
Winfield Hospital considers that this data is as described for the following
reasons:
There have been no patient deaths at the Winfield hospital in the periods shown.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
By maintaining a strong focus on preadmission processes, staff training and
competencies.
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
Winfield
NVC22
*
NVC22
*
Winfield Hospital considers that this data is as described for the following
reasons:
Our patient numbers are too small to participate in this table.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
We will continue to submit all patient data to PROMS
Quality Accounts 2013/14
Page 24 of 39
PROMS – varicose 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
Winfield
NVC22
*
NVC22
*
Winfield Hospital considers that this data is as described for the following
reasons:
Our patient numbers are too small to participate in this table
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
It is unlikely that we will increase our submission rates due to such low patient
numbers.
PROMS – Hip replacement
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
Winfield
NVC22
21.704
NVC22
*
Winfield Hospital considers that this data is as described for the following
reasons:
Our patients report good outcomes following surgery.
We have good processes in place to ensure that completed questionnaires are
submitted.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
We will increase our patient’s understanding of the importance of PROMS data
and outcome measures as a quality tool for patient choice.
Quality Accounts 2013/14
Page 25 of 39
PROMS – Knee replacement
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
Winfield
NVC22
18.024
NVC22
*
Winfield Hospital considers that this data is as described for the following
reasons:
Our patients report good outcomes following surgery.
We have good processes in place to ensure that completed questionnaires are
submitted.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
We will increase our patient’s understanding of the importance of PROMS data
and outcome measures as a quality tool for patient choice.
Readmissions
Period
Best
Worst
Average
Period
Winfield
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2012/13
NVC22
7.68
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
2013/14
NVC22
7.77
Winfield Hospital considers that this data is as described for the following
reasons:
We have low rates of readmission and believe this to be due to our robust patient
pathways, our excellent discharge protocols and good patient education from
preadmission and throughout the inpatient journey.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
We will continue to monitor patient readmission trends through clinical
governance and medical advisory committee meetings.
We will increase our awareness of any patient readmissions to alternative health
care providers.
Quality Accounts 2013/14
Page 26 of 39
Responsiveness to personal needs
Period
Best
Worst
Average
Period
Winfield
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC22
92.1
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC22
91.6
Winfield Hospital considers that this data is as described for the following
reasons:
We provide excellent customer service and patient care as demonstrated in these
results.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
Patient satisfaction is monitored on a monthly basis with trends discussed at
governance and quality meetings
VTE assessment
Period
13/14 Q3
13/14 Q4
Best
Several 100%
Several 100%
Worst
NT244 63.2%
NT205 67.0%
Average
Eng
95.8%
Eng
96.0%
Period
13/14 Q3
13/14 Q4
Winfield
NVC22
99.2%
NVC22 100.0%
Winfield Hospital considers that this data is as described for the following
reasons:
VTE assessment is an integral part of our patient pathways.
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
VTE will continue to be monitored by clinical audit and reviewed at clinical
meetings
Quality Accounts 2013/14
Page 27 of 39
C Diff rate
Period
Best
Worst
Average
Period
Winfield
2012/13
Several
0
RNA
58.2
Eng
22.2
2012/13
NVC22
0.0
2013/14
Several
0
RVW
30.8
Eng
17.3
2013/14
NVC22
0.0
Winfield Hospital considers that this data is as described for the following
reasons:
We have an excellent record of infection and prevention control assessments.
We maintain high standards of cleanliness within the hospital
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
We will continue to ensure that all hospital staff are aware of the principles of
good infection control. We will ensure that our patients and visitors to the hospital
are aware of these standards.
Patient safety incident rate
Period
Best
Worst
Average
Period
Winfield
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
NVC22
6.94
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
2013/14
NVC22
7.3
Winfield Hospital considers that this data is as described for the following
reasons:
All patients undergo a falls risk assessment on admission.
The majority of our patients are elective care which does reduce risk
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
Patient safety incidents will continue to be monitored through risk management
and clinical governance meetings.
Our environment will be monitored and appropriate risk assessments made.
Quality Accounts 2013/14
Page 28 of 39
Friends and Family test
Period
Best
Worst
Average
Period
Winfield
Jan-14
Several
100
RPA02
27
Eng
73
2012/13
NVC22
94
Feb-14
Several
100
RPA02
18
Eng
73
2013/14
NVC22
94
Winfield Hospital considers that this data is as described for the following
reasons:
We actively encourage our patients to complete the friends and family test.
Customer service is a priority to us
Winfield Hospital intends to take the following actions to improve this rate
and so the quality of its services;
We will maintain our high standards of customer service.
We will continue to maintain our staff training in this discipline.
Our friends and family responses will be monitored on a monthly basis.
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs within this section.
Quality Accounts 2013/14
Page 29 of 39
3.2.1 Infection prevention and control
Winfield Hospital has a very low rate of hospital acquired infection and has
had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:








Bi monthly infection control meetings.
Annual mandatory training for all staff in hand hygiene and infection control
measures.
Excellent links with our local NHS Trust.
Monthly audits of our environment by either clinical or housekeeping
measures.
Monthly infection prevention and control audits
Training in non touch technique as per national guidelines
Annual hospital infection control plan
Annual infection control report
Quality Accounts 2013/14
Page 30 of 39
Infection Rates
Infection Rates
(percentage of Admissiosns)
1.2
1
0.8
0.6
0.4
0.2
0
2011/12
2012/13
2013/14
Winfield Hospital
Our infection rates at 1% of all patient admissions are low. All infections are
monitored by the infection control, clinical governance and medical advisory
committees. Trends are looked for and robust actions put in place should any be
suspected. Our reporting is excellent and follow up of incidents thorough and
transparent.
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 Winfield Hospital, providing us with a
patient’s eye view of the buildings, facilities and food we offer, giving us a clear
picture of how the people who use our hospital see it and how it can be
improved.
The main purpose of a PLACE assessment is to get the patient view.
Audit scores October 2013
Cleanliness
Food
Privacy and Dignity
Facilities
WINFIELD HOSPITAL
99.4%
93.2%
90.9%
95%
NATIONAL AVERAGE
95.7%
85.4%
88.9%
88.7%
Quality Accounts 2013/14
Page 31 of 39
Our privacy and dignity scored lowest because of minor waiting area issues within
the hospital that could impact on a small number of patients and this is being
reviewed. Despite this though, we scored well above the national average in all
areas.
Further information on PLACE audit can be found on the following link:
http://www.england.nhs.uk/ourwork/qual-clin-lead/place/
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.
Through our risk management tool RISKMAN we are able to monitor all adverse
events both clinical and non clinical. Reports generated from the system are
reviewed at Health and Safety, governance and medical advisory committee
meetings.
All incidents are reviewed by heads of departments with root cause analysis
done, action plans created and lessons learnt shared.
Staff continue to receive training in risk assessment, moving and handling and fire
safety.
The hospital has a business continuity policy which is reviewed annually. This
covers all areas of potential hazards which could affect patient, staff and building
security.
Annual Health and Safety plans are written and shared across the hospital
Quality Accounts 2013/14
Page 32 of 39
3.3 Clinical effectiveness
Winfield Hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
Ramsay Health Care UK is treating significantly higher numbers of patients every
year as our services grow. The majority of our patients undergo planned surgical
procedures and so monitoring numbers of patients that require a return to theatre
for supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. Ramsay’s rate of return is very low
consistent with our track record of successful clinical outcomes.
Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.5
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Winfield Hospital
Quality Accounts 2013/14
Page 33 of 39
As seen in the graph, our returns to theatre are considerably lower than the
previous year. As part of our clinical governance processes we monitor returns to
theatre, looking for trends by consultant, time of day, procedure etc but have
found no specifics or areas for concern across the last 12 months.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
 Continuous patient satisfaction feedback via a web based invitation
 Hot alerts received within 48hrs of a patient making a comment on their web
survey
 Yearly CQC patient surveys
 Friends and family questions asked on patient discharge
 ‘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
Quality Accounts 2013/14
Page 34 of 39
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently
of the hospital so we receive a true reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked
are used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Manager within 48hrs of receiving them so that a response can be made to the
patient as soon as possible.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
94.0
96.0
2012/13
2013/14
20
0
Winfield Hospital
As can be seen by the above graph our overall patient satisfaction is high and
has been at this level for a number of years.
Quality Accounts 2013/14
Page 35 of 39
3.4 Winfield Hospital patient feedback
(Received via the Friends and Family test)









Could not have asked for friendlier staff and greater care.
Excellent care - staff have been so kind
Very friendly staff excellent cleanliness very good aftercare
Very professional with everything they do from the bottom end to the top end. 10
out of 10.
Everyone was extremely kind and all the services were very good. The stay could
have hardly have been better.
Excellent care and surroundings. Very clean. Felt very safe and informed of
procedures. Kind staff
Excellent staff/Good care
Great ratio of nursing physio, domestic staff to patients.
I have received wonderful care from all of the staff at the hospital from admin to
medical to the ward staff. It has made an enormous difference to my experience
at the Winfield.
 Post op care and friendliness professionalism and patience.
 Staff extremely polite, courteous and helpful. Food excellent as well as nursing
care.
 All staff from outpatients to being released from surgery have been very good.
 Attentive care, kept well informed, careful identity checks, pleasant caring staff
including the domestic staff. Clean, care and concern are very top of the list and it
counts.
 . Room clean, caring staff, all surgeon and nurses. Would definitely recommend.
 Excellent care treatment at all times. Outstanding communication with staff was
perfection.
 Excellent - staff knowledge
 Good care.
 Happy with everything
 I was very impressed with the great care and kindness I have been shown.
 Standard of care
 The care and treatment given to me was excellent and thanks all staff concerned
in my wellbeing.
 The staff from consultant to nursing and general staff were most considerate,
helpful and approachable. The facilities were 1st class.
 Very well looked after by all levels of staff.
 Excellent service thanks for looking after me.
 Good staff very clean and comfortable. Food was good too. Thanks to all
 Besides the procedure itself the rest of the time here was pleasant. The nature of
the procedure itself was not nice but it was done well and I was kept well
informed etc
Quality Accounts 2013/14
Page 36 of 39
Appendix 1
Services covered by this quality account
Treatment of
Disease, Disorder
Or injury
Surgical
Procedures
Services Provided
Peoples Needs Met for:
Cardiology, Chiropody and
podiatry, Cosmetics,
Dermatology, Ear, nose and
throat (ENT), Elderly care,
Endocrinology,
Gastroenterology, General
medicine, Genito-urinary
medicine, Gynaecology,
Neurology, Ophthalmology,
Orthopaedic medicine, Pain
management, Paediatric
medicine, Psychology,
Physiotherapy, Rheumatology,
Sports medicine, Urology
All adults 18 yrs and over
Ambulatory, Day and Inpatient
Surgery, Colorectal,
Cosmetics/plastics, Ear, Nose
and Throat (ENT),
Gastrointestinal, General
surgery, Gynaecology,
Neurology, Ophthalmic, Oral
maxillofacial, Orthopaedic,
Urology
All adults 18yrs and over. Children and young person’s 0yrs -18yrs
excluding:
Children and young persons - 0 yrs to 18yrs and above outpatients
consultations diagnosis and treatments











Patients with blood disorders (haemophilia, sickle cell,
thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA screen are deferred
until negative
Patients who are likely to need ventilatory support post
operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to ITU post
surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g.
from kitchen to bathroom or dyspnoea at rest)
Poorly controlled asthma (needing oral steroids or has had
frequent hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal activity e.g. 1 flight
of stairs or angina at rest)
CVA in last 6 months
BMI > 35 (individual cases will be reviewed by an anaesthetist)



All patients will be individually assessed and we will only exclude patients if
we are unable to provide an appropriate and safe clinical environment.
Diagnostic and
GI physiology,
All adults 18 yrs and over
screening
Imaging services
All children and young person’s 0yrs to 18 yrs
Quality Accounts 2013/14
Page 37 of 39
Appendix 2 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
Page 38 of 39
Winfield 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
01452 331111
Hospital website
http://www.ramsayhealth.co.uk/hospitals/winfield-hospital
Quality Accounts 2013/14
Page 39 of 39