Clifton Park Hospital - NHS

Clifton Park Hospital Quality Account 2012/2013

Quality Accounts 2012/2013 Page 2 of 55

Contents

Contents Page 2

Welcome to Ramsay Health Care UK 4

Welcome to Clifton Park Hospital 5

Introduction to our Quality Account 6

PART 1 – STATEMENT ON QUALITY

1.1 Statement from the General Manager 7

1.2 Hospital accountability statement 9

PART 2 – QUALITY PRIORITIES AND MANDATORY STATEMENTS

2.1 Quality Priorities 10

2.1.1 Review of clinical priorities 2012/13 (looking back) 10

2.1.2 Clinical Priorities for 2013/14 (looking forward) 16

2.2 Mandatory statements relating to the quality of NHS services provided

19

2.2.1 Review of Services 19

2.2.2 Participation in Clinical Audit 20

2.2.3 Participation in Research 22

2.2.4 Goals agreed with Commissioners 23

2.2.5 Statement from the Care Quality Commission 23

2.2.6 Statement on Data Quality 23

2.2.7 Stakeholders views on 2012/13 Quality Accounts 26

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.0 Review of quality performance 28

3.1 Patient Safety 30

3.1.1 Infection prevention and control 30

3.1.2 Cleanliness and hospital hygiene 32

3.1.3 Safety in the workplace 32


3.2 Clinical Effectiveness 33

3.2.1 Return to theatre 33

3.2.2 Readmission to hospital 34

3.3 Patient Experience 34

3.3.1 Patient satisfaction surveys 35

3.3.2 Patient reported outcome measures (PROMS) 36

3.4 Case Study 38

Appendix 1 – Clinical Audits 40

Appendix 2 – CQUIN schedule 41


Welcome to Ramsay Health Care UK

Clifton Park 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 22 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, PCTs and acute Trusts.

“Ramsay Health Care UK is committed to establishing an organisational

culture that puts the patient at the centre of everything we do. As Chief

Executive of Ramsay Health Care UK, I am passionate about ensuring that

high quality patient care is at the centre of what we do and how we operate

all our facilities. This relies not only on excellent medical and clinical

leadership in our hospitals but also upon our overall continuing commitment

to drive year on year improvement in clinical outcomes.

“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. 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.”

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)


Welcome to Clifton Park Hospital Clifton Park Hospital was purpose built and opened in January 2006 to deliver elective NHS activity. In October 2010 the hospital secured a three year standard acute contract (SAC) with NHS NYY and NHS ERY to deliver orthopaedic services. In April 2012 this contract was extended a further 6 months until April 2014 and is now commissioned by Vale of York Clinical Commissioning Group acting as co-ordinating commissioner and Scarborough and Ryedale, East Riding of Yorkshire, Harrogate & Rural District and Hambleton, Richmondshire & Whitby Clinical Commissioning Groups as associates. In addition to this SAC activity, additional orthopaedic activity from York Trust is undertaken. The hospital is also recognised by most major insurance companies and undertakes self pay and insured work.

Brief description of unit and facilities Clifton Park Hospital is a 24 bedded in patient unit providing a wide range of elective orthopaedic surgical procedures including treatments for problems with hips, knees, shoulders, hand, wrist and elbow and foot and ankle. The hospital has a large out patients department, on-site x-ray and physiotherapy (including a small gym), mobile MRI, a day case unit, two laminar flow theatres and a restaurant which is open to staff, patients and visitors. The hospital provides a full range of high quality orthopaedic services, these include, outpatient consultation, outpatient procedures, investigations/diagnostics, surgery and follow up care for all patients of 18 years and above. From 1st April 2012 to 31st March 2013 the hospital has treated 3010 admitted patients, 95% of which were treated under the care of the NHS. The hospital has a unique structured secondment agreement with York Teaching Hospitals NHS Foundation Trust who provide 40 specialist consultant orthopaedic surgeons and anaesthetists to work from the facility. The hospital also has a training agreement with York Trust, enabling registrars and extended scope practitioners to work alongside consultants at the hospital. Our seconded clinicians are supported by a team of 42 Nursing staff, 13 Health Care Assistants, 12 Allied Health Professionals and 41 support staff which includes porters, hotel services and 23 administration staff. The hospital’s Resident Medical Officer is on site 24 hours a day, working alongside these teams. Our staff-to-patient ratios are managed on a daily basis to meet the individual clinical requirements of our patients. As well as our secondment agreement with York Teaching Hospitals NHS Foundation Trust, we have in place, several service level agreements with them to facilitate our service delivery and ensure continuity of care.


Introduction to our Quality Account

This Quality Account is Clifton Park 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.

Each Ramsay site has developed its own Quality Account. It includes some Group

wide Initiatives, but describes the many excellent local achievements and quality

plans that we would like to share.


Part 1 1.1 Statement on quality from the General Manager

Debbie Craven, General Manager, Clifton Park Hospital

“Clifton Park Hospital successfully delivered the GC4 contract from January 2006 to September 2010. In October 2010 we commenced a three year standard acute contract, commissioned by NHS NYY and NHS ERY following a tender process where we demonstrated our continuing high level of quality service delivery this contract was extended a further 6 months in April 2013.”

This is the third Quality Account to be submitted by Clifton Park Hospital (CPH) and has been produced to demonstrate our commitment to measuring all feedback from patients about their experience, clinical treatment and clinical outcomes. This allows us to continually review, reflect and improve the patient’s journey. Our hospital vision statement, which will be reflected throughout this report, is that: “Clifton Park Hospital is committed to being a leading provider of orthopaedic health care services by delivering high quality outcomes for patients at efficient cost ensuring profitability.” Patient safety is our highest priority and our robust recruitment processes and training programmes ensure that staff are competent and fully trained in all aspects of service provision. Clifton Park Hospital continually achieves consistently high patient satisfaction scores and, by studying results throughout the year, we constantly seek ways to further improve the patient experience. Clifton Park Hospital is committed to ensuring that patients are kept fully informed about their treatment, which is also a significant factor associated with improving treatment outcomes. We involve our patients in treatment decisions at the earliest stage so that the options and benefits are fully discussed before patients consent to treatment. Our medical and clinical teams recognise the importance of devoting time to patient preparation for surgery, which not only reduces risk but also improves patient understanding and confidence, reduces anxiety, improves rates of recovery and shortens lengths of hospital stay. Whilst patient feedback and involvement is extremely important to us, we also rely heavily on other measures of safety and clinical effectiveness which we use to satisfy ourselves that treatment is evidence-based and delivered by appropriately qualified and experienced doctors, nurses and other key healthcare professionals. Examples of these are detailed in this Quality Account.


Clifton Park Hospital is accustomed to the disciplines of regulatory and contractual requirements to assure healthcare commissioners of our clinical performance and to report complaints and serious incidents to regulators and commissioners. We also maintain a Risk Register and systematically review specific actions to achieve risk reduction.


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.

Debbie Craven General Manager Clifton Park Hospital Ramsay Health Care UK This report has been reviewed and approved by: Mr Ian Whitaker – MAC Chairman Mrs Gwenn Mather - Clinical Governance Chair Mr Stefan Andrejczuk – Regional Director North


Part 2

2.1 Quality priorities for 2013/14

Plan for 2012/13 On an annual cycle, Clifton Park Hospital develops an operational plan to set objectives for the year ahead. We have a clear commitment to our patients and work in close 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 those experiencing our services. To meet these aims, we have various initiatives ongoing 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.

Priorities for improvement 2.1.1 A review of clinical priorities 2012/13

Patient Safety

VTE risk assessment – Clifton Park Hospital carries out a VTE risk assessment on all admitted surgical patients as per Ramsay Policy No CM001 and adhering to National Institute for Clinical Excellence (NICE) Guidance 2010. The aim being to reduce the risk of patients suffering a venous thrombo embolism following surgery

All nursing staff have undertaken VTE competency assessment via DoH on line

assessment tool.

From 1st October 2010, Clifton Park Hospital entered into a contract for the provision of NHS services through the Commissioning for Quality & Innovation Payment Framework (CQUIN). Payment is conditional on achieving quality


improvement and innovation goals, this includes VTE risk assessment. Compliance is audited through a robust corporate and local audit programme and results/action plans reviewed through Clinical Governance.

VTE compliance results are benchmarked through the National Statistics at http://www.dh.gov.uk/en/publicationsandstatistics/Publications/PublicationsStatistics/DH

NHS Safety Thermometer (with effect from April 2012). This is a mandatory section of Quality Requirements and Nationally Specified Events (CQUIN) that we are required to report on. In addition to VTE compliance and falls, the other reportable elements are Pressure Ulcers and Urinary Tract Infections. In order to demonstrate compliance with this measurement, a monthly 24 hour prevalence audit, using the NHS Safety Thermometer Survey tool is conducted and submitted on line. In total 253 patients were included in the survey as above with an outcome of 100% of patients receiving harm free episodes of care

National Joint Registry (NJR) – Clifton Park Hospital participates in the National Joint Registry audit programme. Patients undergoing hip or knee replacement surgery are asked to consent to their information being placed upon the NJR including details of their prosthesis. The NJR provide a quarterly report to the hospital regarding compliance.

80

82

84

86

88

90

92

94

96

98

100

0.8

0.82

0.84

0.86

0.88

0.9

0.92

0.94

0.96

0.98

1

Clifton Park NHS Treatment Centre

Excellent

Good

Fail

Current

Target

http://www.dh.gov.uk/en/publicationsandstatistics/Publications/PublicationsStatistics/DH

http://www.dh.gov.uk/en/publicationsandstatistics/Publications/PublicationsStatistics/DH


Clifton Park exceeds the national 90% benchmark figure for NJR consent as demonstrated in the results below. NJR consent compliance has risen to 100% in the last two quarters and submission of BMI rate has increased over the past year as tabled

Clifton Park Hospital 2012/13 Q1

2012/13 Q2

2012/13 Q3

2012/13 Q4

Submission Volumes 201 201 225 230 Consent & link ability % 98 99 100 100 BMI Rate % 97 99 98 98

0.5

0.55

0.6

0.65

0.7

0.75

0.8

0.85

0.9

0.95

1

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Clifton Park Hospital

Actual

95% Target


A new Pathology service was implemented in April 2012, providing both off-site analyses and onsite Point of Care Testing (POCT) and analyses. The advantage of the service is the ability to access electronic reports immediately, ensuring an efficient service for patients. A very comprehensive Blood Transfusion Service continues to be provided by York Trust Hospital under a Service Level Agreement. Consultant Microbiology input is also available through a Service level agreement with local Consultant microbiologists.

Clinical Effectiveness

Better outcomes and improving Patient experience Pain control - Patients have the right to care that promotes comfort and minimizes pain. Ramsay Healthcare set up a committee of experienced Clinicians to develop guidelines and protocols for pain control following surgery. A member of Clifton Park Hospital clinical team was part of this committee and we were also a pilot site for the policy implementation. Taking into account NICE and other best practice guidance, (Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020); Nursing and Midwifery Council (2007) Standards for Medicine Management) the following were introduced: A policy on “Acute post-operative pain management in Adults”; a pain assessment tool, and a patient information leaflet “Managing your Pain after your operation” have all been implemented very effectively and patient survey results show that we have exceeded our target of 90% patients saying “Yes” to the Questions;

Did a member of staff explain the purpose of the medications you are toi take home in a way you could understand?

Do you think the nurses did everything they could to control your pain? This is demonstrated in the table below, showing a sample quarter survey as reported to the CCG (formally the PCT). Pain Control is also a local CQUIN measure for Clifton Park Hospital


Month No of patients

No of responses

% Question Yes Yes Definitely

Yes to some Extent

No N/A %

July 12

248

186

75%

Were you Ever in Pain

106

80

Do you think the nurses did everything they could to help control your pain

184 2 99%

Did a member of staff explain the purpose of the medications you are to take home In a way you could understand

184 2 100%

August 12

213

132

61%


91

41


131 1 99%


130 2 100%

September 12

226

153

67%


100

53


151 1 1 98.7%


147 6 100%

Ambulatory Day Care As part of Ramsay’s National Project for Ambulatory Day Care services, Clifton Park Hospital has:

Appointed an Ambulatory Care lead nurse who is a member of the British Association of Day care Surgery (BADS).

Facilitated the ambulatory process by aiming to place day care patients first on operating lists or as clinically indicated.

Developed an action plan to implement staggered admission times where appropriate to improve the patient experience, aiming to reduce the waiting time from admission to procedure.

Further enhanced efficiencies at Clifton Park Hospital by implementing a nurse led discharge service within our Ambulatory day care unit.

On discharge, patients are provided with contact details should they have any post operative problems and receive a post discharge phone call within 48 hrs of discharge. The Satisfaction rating of waiting time from admission to procedure still remains at 82% so this is still an area of focus and will be addressed as part of the Patient journey mapping process


Patient experience – informing patient choice

Increasing the use of Patient Reported Outcomes Studies (PROMs) – Clifton Park Hospital uses the National PROMS results for hip and knee replacements patients. These are used to gain a better understanding of treatment outcomes from a patient point of view. Results are shared with Consultants at our Clinical Governance meetings. All members of the multi-disciplinary team are encouraged to review the PROMs outcomes and changes made as required to improve the patient experience. Clifton Park Hospital was below the target of 79.6% of submitting completed consent form for patient undergoing Hip Replacement surgery. Increased focus on this- particularly at the pre assessment stage of the patient pathway, has increased our compliance rate to 84.2%, as demonstrated in the graph below.

National compliance rates for consent

79.6 % hips

81.9% knees

Patient Experience – personal needs. This is a mandatory section of Quality Requirements and Nationally Specified Events (CQUIN) that we are required to report on. Looking at 5 question, each describes a different element of the overarching theme “responsiveness to personal needs”:

1. Involved in decisions about care/treatment 2. Hospital staff available to talk about worries/ concerns 3. Privacy when discussing treatment 4. Informed about medication side effects 5. Informed who to contact if worried after leaving hospital

Compliance rate of Clifton Park Hospital submitting completed consented forms

84.2% 84.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hips Knees


The composite value required for CQUIN is above 80% for the response “Yes definitely/always” and “no worries fears/ did not need explanation” and the above results from the 2012 NHS survey demonstrates a score of 85.4%

2.1.2 Clinical Priorities for 2013/14 Patient Safety

Informed 2 stage Consent: It is Ramsay policy that consent will be initiated at the earliest stage and evidenced by the first stage of the consent form being completed and the patient confirming receipt of information to allow him/her to make an informed choice of whether to proceed with the procedure and satisfactory period of time to ask further questions or be provided with further information. The second stage will be on the day of procedure prior to the patient transfer to the procedure/operating suite.

Clifton Park Hospital aim to achieve 2 stage consent for all patients, however this will not be possible with patients who are admitted under the “Direct to list” process (via MSK).

Question Answer Score

Involvement about decisions in treatment/Care Yes Definitely 81.0%

Yes to some extent 17.0%

No 2.0%

Hospital staff being available to talk about worries/concerns Yes Definitely 24.0%

Yes to some extent 14%

No 3%

Had no worries/fears 60%

Privacy when discussing condition/Treatment Yes always 93%

Yes Sometimes 6%

No 1%

Informed about medication side effects Yes Completely 45%

Yes to some extent 16%

No 12%

Did not need an explanation 27%

Informed who to contact if worried after leaving hospital Yes 97%

No 2%

Don't know/can’t remember 1%


National Safety Thermometer – this is an ongoing National CQUIN measurement undertaken through pre-determined monthly prevalence survey. Please refer to table below.


Remapping of the patient journey process from referral to discharge from hospital, to identify areas for improved efficiencies and patient outcomes (to include staggered admission times to reduce wait from admission to procedure for inpatients and improve our score of 82 %.)

CQUIN Measures – a mandatory requirement (as below)

PROMS – a mandatory requirement

RAMSAY - 2013/14 CQUIN SCHEME

Quality Domain

Goal Number Goal Name Description of Goal

Goal Weighting VOYCCG (% of CQUIN scheme available)

Goal Weighting SRCCG Safety Effectiveness

Patient Experience Innovation

1 Friends & Family Test

Improve patient experience. F&FT will provide timely, granular feedback from patients about their experience.

0.167% 0.167% Yes

2 NHS Safety Thermometer

Reduce harm. The power of the NHS Safety Thermometer lies in allowing frontline teams to measure how safe their services are and to deliver improvement locally.

0.166% 0.166% Yes Yes

3 VTE Reduce avoidable death, disability and chronic ill health from Venous-thromboembolism (VTE)

0.167% 0.167% Yes

4 Pain Management Proactively help patients with pain management following surgery

1.000% 1.000%

5 Electronic Discharge Letters to GPs

All discharge letters to be emailed to GPs in VOYCCG

1.000% 1.000%

Total


Patient experience

Friends and Family survey: From April 2013, all patients will be asked a

simple question to identify if they would recommend a particular A&E

department or ward to their friends and family. The results of this friends and family test will be used to improve the experience of

patients by providing timely feedback alongside other sources of patient feedback. It will highlight priority areas for action. This is a national CQUIN measure for Clifton Park Hospital.

Patient discharge letters to be sent electronically to GP within 24hrs of discharge from hospital. Patient discharge letters are presently in paper form. The move to electronic letters will improve timeliness, efficiency and address legibility issues.

Actions from patient survey outcomes from the 2012 NHS Patient survey and “We Value Your Opinion” required to improve waiting times from admission to theatre and fasting times. This will be addressed in conjunction with the Patient journey mapping process as described in Clinical Effectiveness Priorities


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 2012/13, Clifton Park Hospital provided Elective Orthopaedic NHS services. Clifton Park Hospital continually reviews all the data available to them on the quality of care provided. The income generated by the NHS services reviewed from 1 April 2012 to 1 April 2013 represents approximately 95% per cent of the total income generated from the provision of services by Clifton Park Hospital during this period. 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 Managers. 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 2012/13, the indicators on the scorecard which affect patient safety and quality were:

Human Resources

HCA Hours as a % of Total Nursing hours is 31%

Agency Hours as % of Total Hours is 0.004%

4.8% Staff Turnover

3.29% Sickness

Mandatory Training = 85% completed in last 12 months

Number of Significant Staff Injuries = 0

Appraisals = 87% completed in last 12 months Patients

11 x Formal complaints 1st April 2012 to 31st March 2013 = 0.36 %

92% Patient Satisfaction Score

1 Significant reportable incidents during 2012 = 0.03%

2 Readmissions patients in 2012 = 0.6% readmissions per 1000 Admissions

0 EMSA (Eliminating Mixed Sex Accommodation) breaches


Quality Our overall Infection Control Audit score is 99%. A comprehensive Health, Safety and Facilities audit is carried out annually. This internal audit returned a score of 96% compliance and an action plan has been developed to correct the key areas identified. (2012 score 94%) A Disability Discrimination Act audit was carried out in January 2013.

2.2.2 Participation in Clinical Audit During 1 April 2012 to 31 March 2013, five national clinical audits and National Confidential Enquiries covered NHS services that Clifton Park Hospital provides. The national clinical audits and national confidential enquiries that Clifton Park Hospital was eligible to participate in during 1 April 2012 to 31March 2013 are as follows: National Clinical Audits and National Confidential Enquiries (NA = not applicable to the services provided) For information/reports on audits participated in please go to the following link: http://www.hqip.org.uk/ncas-for-qa-introduction/

Name of Audit Participation % cases submitted

Peri-and Neo-natal N/A – no service

Children N/A – no service

Paediatric pneumonia (British Thoracic Society) N/A – no service

Paediatric asthma (British Thoracic Society) N/A – no service

Pain management (College of Emergency Medicine) N/A – no service

Childhood epilepsy (RCPH National Childhood Epilepsy Audit) N/A – no service

Paediatric intensive care (PICANet) N/A – no service

Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit)

N/A – no service

Diabetes (RCPH National Paediatric Diabetes Audit) N/A – no service

Acute care

Emergency use of oxygen (British Thoracic Society) N/A – no service

Adult community acquired pneumonia (British Thoracic Society) N/A – no service

Non invasive ventilation -adults (British Thoracic Society) N/A – no service

Pleural procedures (British Thoracic Society) N/A – no service

Severe sepsis & septic shock (College of Emergency Medicine) N/A – no service

Adult critical care (ICNARC CMPD) N/A – no service

Potential donor audit (NHS Blood & Transplant) N/A – no service

Seizure management (National Audit of Seizure Management) N/A – no service

Long term conditions

Diabetes (National Adult Diabetes Audit) N/A – no service

http://www.hqip.org.uk/ncas-for-qa-introduction/


Name of Audit Participation % cases submitted

Heavy menstrual bleeding (RCOG National Audit of HMB) N/A – no service

Chronic pain (National Pain Audit) N/A – no service

Ulcerative colitis & Crohn's disease (UK IBD Audit) N/A – no service

Parkinson's disease (National Parkinson's Audit) N/A – no service

Adult asthma (British Thoracic Society) N/A – no service

Bronchiectasis (British Thoracic Society) N/A – no service

Elective procedures

Hip, knee and ankle replacements (National Joint Registry) YES 100%

Elective surgery (National PROMs Programme) YES 100%

Intra-thoracic transplantation (NHSBT UK Transplant Registry) N/A – no service

Liver transplantation (NHSBT UK Transplant Registry) N/A – no service

Coronary angioplasty (NICOR Adult cardiac interventions audit) N/A – no service

Peripheral vascular surgery (VSGBI Vascular Surgery Database) N/A – no service

Carotid interventions (Carotid Intervention Audit) N/A – no service

CABG and valvular surgery (Adult cardiac surgery audit) N/A – no service

Cardiovascular disease

Acute Myocardial Infarction & other ACS (MINAP) N/A – no service

Heart failure (Heart Failure Audit) N/A – no service

Acute stroke (SINAP) N/A – no service

Cardiac arrhythmia (Cardiac Rhythm Management Audit) N/A – no service

Renal disease

Renal replacement therapy (Renal Registry) N/A – no service

Renal transplantation (NHSBT UK Transplant Registry) N/A – no service

Cancer

Lung cancer (National Lung Cancer Audit) N/A – no service

Bowel cancer (National Bowel Cancer Audit Programme) N/A – no service

Head & neck cancer (DAHNO) N/A – no service

Oesophago-gastric cancer (National O-G Cancer Audit) N/A – no service

Trauma

Hip fracture (National Hip Fracture Database) N/A – no service

Severe trauma (Trauma Audit & Research Network) N/A – no service

Psychological conditions N/A – no service

Blood transfusion

Medical use of blood (National Comparative Audit of Blood Transfusion)

N/A – no service

Health promotion

Risk factors (National Health Promotion in Hospitals Audit)

End of life

Care of dying in hospital (NCDAH) N/A – no service

Additional Audits

National Surveillance Programme (HPA) YES 100%

PEAT YES N/A

The reports of three national clinical audits from 1 April 2012 to 31 March 2013 were reviewed by the Clinical Governance Committee at Clifton Park Hospital


Local Audits Clifton Park Hospital participates in the Ramsay Corporate Audit programme (the schedule can be found in appendix 2) all of which go through the Clinical Governance Committee and actions taken recorded to improve the quality of the healthcare provided:- The following actions were indicated by the outcomes of the following audits (based on a random selection of 10 sets of patients’ medical records) that fell below 90%.

The Deteriorating Patient: scored only 86% Sept 2012 due to not all staff completing scoring tool correctly despite undertaking all relevant observations. Further training was completed and repeat audit in March 2013 indicated an improved score of 92%

VTE Risk assessment: scored only 60% in August 2012 due to the Consultants not signing the completed risk assessments undertaken by nursing staff. Following discussions with medical staff this improved to 85% in February 2013. All patients undergo VTE risk assessment prior to surgery by the nursing team. The completed risk assessment form is retained in the patient’s medical records, the outcome is documented in the patients paper care pathway and again electronically on the Patient administration system to include all prophylaxis applied. The consultants document the required prophylaxis on the operating notes and chemical prophylaxis is transcribed to the drug prescription form by the resident medical officer, however the consultants occasionally fail to sign the completed risk assessment form, thus loosing vital audit scores. Consultants have been encouraged to completed this part of the process and compliance is improving

Physiotherapy records: scored 89% March 2012 due to failure to complete all details in documentation, an action plan was put in place to address this and the audit repeated in March 2013 showed an improvement to 96% compliance

2.2.3 Participation in Research Approved research of “A Prospective, Non Comparative, Multicentre, Multinational Study to Determine the Performance & Survivorship of the Sigma HP Partial Knee System” commenced in June 2012, However the study was discontinued in April 2013, due to the low compliance of other study sites Corporate Clinical Governance granted permission for Clifton Park Hospital to participate into Ethics Committee Approved research of “Prospective, Single Arm Multiconfiguration Investigation to Assess the Functional Performance of Attune Primary Total Knee Arthroplasty System” which commenced in October 2012. This study is going well


We also obtain consent from patients to donate bone samples to York University to aid their research into osteoporosis this has been approved by research ethics committee.

2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework

A proportion of Clifton Park’s income from 1 April 2012 to 31st March 2013 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. See Appendix 2 for our Schedule.

2.2.5 Statement from the Care Quality Commission (CQC) Clifton Park Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions An unannounced inspection of Clifton Park Hospital was undertaken on 31st January 2013 and all standards were met with full compliance. The Care Quality Commission has not taken enforcement action against Clifton Park Hospital during 2012/13. Clifton Park Hospital was identified as an outlier for hip revisions in the National Joint Registry 9th Annual Report and was contacted by the Care Quality Commissions Surveillance manager. A detailed response was provided regarding metal on metal hip replacements and recall process. The CQC responded ‘We have reviewed the information you have provided and do not feel that we need to undertake additional enquiries at this time’

2.2.6 Data Quality Data Quality is taken very seriously at Clifton Park Hospital. The quality of our data, whether this is in the form of local audits, paper records, or data submitted to the DoH or CCGs, reflects directly on the quality of the services provided at the hospital. As part of our Standard Acute Contract, we are required to demonstrate that we monitor and improve data, to support care quality which is undertaken through our Clinical Audit programmer. Part of our audit programme covers medical records and anaesthetic records ensuring that key information is recorded throughout the patient journey. The actions required for each audit are documented and discussed at various hospital committee meetings


Audit results for anaesthetic records:

Audit Feb 2012 Aug 2012 March 2013

Anaesthetic records 94% 98% 100%

Audit results for medical records audit:

Audit April 2012 July 2012 Oct 2012 Jan 2013

Medical records audit 100% 98% 100% 100%

Secondary Uses Service (SUS) submissions: During the period April 12 – March 13 Clifton Park Hospital’s SUS submissions were 100%. This score is directly attributable to the hospital’s dedicated data quality team who work alongside all departments in the hospital to ensure that all data is entered correctly and also the suite of reporting tools available through Ramsay’s corporate IS team. NHS Number and General Medical Practice Code Validity Clifton Park Hospital submitted records during 2012/13 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics 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: 100% for admitted patient care; 100% for outpatient care; and N/A for accident and emergency care (not undertaken at our hospital). The General Medical Practice Code was: 100% for admitted patient care; 100% for outpatient care; and N/A for accident and emergency care (not undertaken at our hospital). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2012/13 was 77% and was graded ‘green’ (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: https://www.igt.connectingforhealth.nhs.uk/

https://www.igt.connectingforhealth.nhs.uk/


Clinical coding error rate Clifton Park Hospital was not subject to the Payment by Results clinical coding audit during 2012/13 carried out by the Audit Commission. Clifton Park Hospital employs a Clinical Coder who has undertaken the Connecting for Health Clinical Coding Foundation Course in 2011 and is responsible for all diagnostic and procedure coding and is actively involved in audit processes. Ramsay Health Care Information Governance Req 505 Attainment Levels Achieved 2012 Internal Audit

Hospital Site Audit

Date

Primary

Diagnosis

Secondary

Diagnosis

Primary

Procedure

Secondary

Procedure

Clifton Park

Hospital

Feb 12 91.67% 88.37% 96.67% 91.89%


2.2.7 Stakeholders views on 2012/13 Quality Account Copies of this quality account for comment prior to publication have been sent to:

Vale of York Clinical Commissioning Group ( VOYCCG)

Healthwatch York Comments received are published below CLIFTON PARK HOSPITAL QUALITY ACCOUNT STATEMENT 2012/13 Vale of York Clinical Commissioning Group is the lead Commissioner for Clifton Park Hospital and we are pleased to be able to review and comment on their Quality Account for 2012/13 in conjunction with our Associate Commissioner, NHS East Riding of Yorkshire. We have worked hard together as Commissioners and Providers to improve the quality of patient services for our populations. Through the contract management process, Clifton Park Hospital has provided assurance to us as Commissioners, by sharing a range of data and quality metrics which have assured us of the quality of patient services. We are especially pleased to note the following achievements:-

Achievement of all the quality improvement goals in the 2012-13 CQUIN Scheme.

which showed that 100% patients surveyed received harm free episodes of care.

feedback from patients regarding pain control and the care received at Clifton Park Hospital. The priorities identified in the Quality Account for 2013/14 clearly identify with the three elements of quality i.e. patient safety, clinical effectiveness and patient experience and focus on:- Patient Safety

– introduction of 2 Stage Consent process.


arge from hospital which will improve timeliness, efficiency and address legibility issues.

Patient Experience

theatre and fasting times for inpatients.

– ‘no decision about me without me’

of using hospital services. As a commissioner we commend this Quality Account for its accuracy, honesty, and openness. We recognise that Clifton Park Hospital delivers good quality patient care, and we look forward to working with Ramsay Healthcare to bring about further improvements in quality during 2013. Rachel Potts Chief Operating Officer Vale of York Clinical Commissioning Group


Response from Healthwatch York to Clifton Park Hospital Quality Accounts 2012/13 25th June 2013 Thank you for giving Healthwatch York the opportunity to comment on your Quality Accounts for 2012/3. The report is very informative, well laid out and generally easy for lay people to read. It was very pleasing to see that the patient satisfaction survey has been used to identify two areas for improvement which are included in the clinical priorities for 2013/14. In terms of the patient experience, it is re-assuring to see the low rates of re-admission and unplanned return to theatre. It is good to see that the strong focus on patient safety has led to a number of improvements, and that risks to patient safety come to light through a number of routes. The case study about setting up the pre-operative education class was particularly interesting and is a good demonstration of a person centred approach. It is pleasing that the hospital recognises that devoting time to preparing patients for their surgery does improve treatment outcomes. Healthwatch York looks forward to identifying opportunities to work with Clifton Park during the coming year.


Part 3

Statements of quality delivery

Matron, Gwenn Mather

3.0 Review of quality performance 1 April 2012 - 31 March 2013 Introduction

“Our overriding commitment is to provide safe and effective care; the guiding principle is to put our patients’ interests first and key to this is our capacity to listen, be responsive and to act on their feedback. We already take patient views and ratings into account in any assessment of our performance but now we will increasingly draw on effective real-time information and this includes on-line patient surveys. Added to which there are more opportunities to use new measures of quality of care and patient safety and be able to make a difference to improvements in future practice. Importantly these new metrics should ensure performance which needs improving, can be quickly identified and fixed’.

(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)

Ramsay Clinical Governance Framework 2012

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. 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

The Matron at Clifton Park Hospital actively promotes clinical governance and collaborates with NHS partners to ensure that Clifton Park Hospital is informed of relevant initiatives to continually improve the safety and excellence of the services offered. Matron attends a number of district meetings to nurture relationships with key stakeholders/NHS/PCTs (CCGs from April 1st 2013) these include – Quality Performance Group, MCA Group; Local Intelligence Network for Controlled Drugs group.


NICE / NPSA 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. Clifton Park Hospital 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 Patient safety

Clifton Park Hospital is a progressive hospital focussed on improving its performance every year, particularly with regard to 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 demonstrated below: -

3.1.1 Infection prevention and control Clifton Park Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia or Clostridium Difficile since opening in January 2006. We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia, Clostridium Difficile and E coli infections with a programme to reduce incidents year on year. Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and Clifton Park Hospital remains below the lowest percentile for infection rates. 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.


Clifton Park Hospital has its own Infection Control Link Nurse and IPCC is included in our Clinical Governance agenda. Programmes and activities within our hospital include:

Mandatory annual infection prevention and control training.

Infection Control Audit

In–house training i.e. hand washing

Healthcare associated infections (HCAI) are acquired as a result of healthcare intervention. High standards of Infection Prevention and Control practice minimise the risk of occurrence and as can be seen from the bar chart below Clifton Park Hospital has had a low HCAI rate annually for the past 2 years and is well below the National Average.

3.1.2 Cleanliness and hospital hygiene

Assessments of safe healthcare environments also include Patient Environment Assessment Team (PEAT) audits. These assessments include rating of privacy and dignity, food and food service, access issues such as signage, bathroom/toilet environments and overall cleanliness. The graph below shows our PEAT scores over the last 2 years. The latest result indicates improved scoring following the implementation of the redecorating programme demonstrating the improvement to the hospital environment.

PEAT is to be replaced by PLACE (Patient Led Assessment of the Care

Environment) and will be undertaken in June 2013

0

1

2

10/11 11/12 12/13

Hospital Acquired Infections



3.1.3 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. Staff at Clifton Park Hospital have a high awareness of safety which has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. The addition of an electronic system “Riskman” in August 2012 enables the central corporate collation of information regarding adverse events and complaints. This in turns enables the ability to identify trends both locally and corporately 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 as soon as received 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 Managers who ensure we keep up to date with all safety issues Adverse Incidents and near misses reported at Clifton Park Hospital:

2011 = 12.5 per 1000 admits (to March 31st)

2012 = 7.6 per 1000 admits (to March 31st)

2013 = 5 per 1000 admits ( to March 31st) The incidents reported include patients, visitors, staff and sub-contractors who utilise and access the Hospital. The above figures indicate that we encourage the reporting of all incidents no matter how minor, reflecting a raised awareness of the importance of safety in the workplace.

PEAT audit results 2011 ; 2012

99% 99.20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2011 2012


3.2 Clinical effectiveness

Clifton Park Hospital has a Clinical Governance team and committee (to include Consultant surgeon and Consultant Anaesthetist) that meet regularly through the year to monitor quality and effectiveness of care. Key performance indicators, clinical incidents and complaints, patient and staff feedback, training and development and infection control 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.

3.2.1 Return to theatre

Ramsay is treating significantly higher numbers of patients every year as our services grow. The majority of our patients undergo planned surgical procedures and so monitoring numbers of patients that require a return to theatre for supplementary treatment is an important measure. Every surgical intervention carries a risk of complication so some incidence of returns to theatre is normal. The value of the measurement is to detect trends that emerge in relation to a specific operation or specific surgical team. Ramsay’s rate of return is very low consistent with our track record of successful clinical outcomes

As can be seen in the above graphs our return to theatre rate remains very low. These figures are constantly monitored throughout the year via our clinical governance and medical advisory committee framework.

Jan

Feb

Mar

Apr

May

Jun

Jul Aug

Sep

Oct

Nov

Dec

Unplanned Return to Theatre Number

0 0 0 0 0 0 0 0 0 1 0 0

Unplanned Return to Theatre Rate

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.0% 0.0%

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0

0.2

0.4

0.6

0.8

1

1.2

Rate

Nu

mb

er

Unplanned Returns to Theatre 2012


3.2.2 Readmission to hospital

Monitoring rates of re-admission to hospital is another valuable measure of clinical effectiveness. As with return to theatre, any emerging trend with specific surgical operation or surgical team in common may identify contributory factors to be addressed. Ramsay rates of readmission remain very low and this, in part, is due to sound clinical practice ensuring patients are not discharged home too early after treatment and are independently mobile, not in severe pain etc.

As can be seen in the above graphs our readmission to hospital rate has remained very low over the last 2 years. These figures are constantly monitored throughout the year via our clinical governance and medical advisory committee framework.

3.3 Patient experience

All feedback from patients regarding their experiences at Clifton Park Hospital 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 behavior – letters and cards are displayed for staff to see in staff rooms and on notice boards. Managers ensure that positive feedback from patients is recognized and any individuals mentioned are praised accordingly. All negative comments or suggestions for improvement are also communicated to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

10/11 11/12 12/13

Readmissions



Patient experiences are fed back 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 DoH bodies occurs as required and according to Ramsay and DoH policy. Feedback regarding the patient’s experience is encouraged in various ways via: Patient satisfaction surveys ‘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 PROMs surveys Care pathways – patients are encouraged to read and participate in their plan of

care.

3.3.1 Patient Satisfaction Surveys On behalf of Ramsay UK, Patient Perspective conducted a survey of NHS inpatients discharged between January and August 2012. As a summary measure for each question, Patient Perspective followed the approach adopted by the Care Quality Commission in England for the National Patient Experience Survey Programme which allows easy benchmarking with existing published national data. The mean rating score allocates a ‘weight’ to each response, with positive scores (e.g. excellent, very good, good) allocated a higher score than negative responses (e.g. fair, poor). For every evaluative question, each response category is weighted between 0 (most negative) and100 (most positive). An average for each question is then calculated with higher scores indicating better results (or a more positive patient experience) and 100 being perfect. Clifton Park Hospital received an overall score of 92% satisfaction for 2012 this was the same score as 2011.


From the NHS patient satisfaction survey it is possible to identify both areas for improvement as well as areas where we excel. Following the publication and communication of the results an action plan is developed. The actions identified from this latest survey include: 1. Waiting times from admission to Procedure 2. Fasting times

These have been included in the clinical priorities for 2013/14

3.3.2 Patient Reported Outcome Measures (PROMs) Clifton Park Hospital participates in the Department of Health’s PROMs surveys for hip and knee surgery for NHS and Private patients. The graph below shows the PROMs data for NHS patients from May 2009 to February 2013. Hip replacement patients

0

5

10

15

20

25

30

35

England CLIFTON PARK NHS TREATMENT CENTRE

YORK TEACHING HOSPITAL NHS

FOUNDATION TRUST

Adjusted average health gain

Oxford Hip Score


Knee Replacement Patients

Access to Clifton Park Hospital and Ramsay’s PROMs results can be found at the following website: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category

0

5

10

15

20

25

30

England CLIFTON PARK NHS TREATMENT CENTRE

YORK TEACHING HOSPITAL NHS

FOUNDATION TRUST

Adjusted average health gain

Oxford Knee Score

http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category


3.4 Clifton Park Hospital

Case Study Pre-operative education class for joint replacement clients

Since the opening of the hospital in 2007 we have had difficulty in setting up a system by which the patients are seen by the therapy team. Initially we had two or three half hour slots a week for the patients to attend; this wasn’t very popular and resulted in low attendance. We then tried holding two sessions, one during working hours and one after hours to try and maximise attendance, again we found that attendance was low. Finally we stopped holding specific sessions and the pre-op nurses would direct patients to us following their clinical assessment, when they would watch a video and speak to a Physiotherapist, but this became increasingly difficult as the department was often busy and the physiotherapist was unavailable to speak to. In May 2012, we employed an Occupational Therapist who is hospital based. In her initial months she familiarised herself with the patient processes and patient requirements. The decision was made to commence pre-operative education classes similar to other hospitals in the area, with the ability to meet eight patients per session. The weekly group sessions commenced in January 2012. The main aim of these sessions is to ensure we focus on our patient’s needs and expectations, and have everything in place for their discharge home following their Joint Replacement surgery. We invite patients who have consented to hip, knee, shoulder and ankle replacement surgery, to join us on a Monday morning, prior to their surgery and discuss what will happen throughout their time with us both as an in-patient and their needs post-discharge. Each session is held by a Physiotherapist and the Occupational Therapist who will discuss the patient’s journey from the day of the operation up until their planned discharge home.

Firstly we discuss what will happen on the day of the operation, and what

comfortable clothing to bring in to wear during the recovery period.

Next we discuss the discharge criteria they will need to achieve before they can

return home. In addition to being clinically well and fully recovered from the

operation, they need, with the exception of shoulder patients, to be mobilising

safe and independently with the aid of sticks (or crutches dependent upon the

consultant), able to perform their exercise regime, be able to wash/shower and

dress, and be able to walk up and down the stairs.


The Occupational therapist then discusses what equipment and/or care we will

be able to provide to each individual in the group. We also ensure each patient is

seen on an individual basis to ascertain more personal needs as required.

We then go back to a group discussion and open the floor to questions.

Basic equipment is also being provided prior to their hospital stay, which allows

patients to practice with this unfamiliar equipment, reducing anxieties.

The Occupational Therapist will also explain safe transfers with the patients, and

if any more specialist equipment is required, there is also time to further assess

and arrange for that equipment to be delivered and fitted, by herself, or the

Community Equipment Store. If this is required, patients have fed back that it is

often nicer to have met the O.T. prior to the home visit and the equipment fitting.

Since starting this group in January, we have ironed out some of the obvious problems when starting anything new, and ask for feedback from the patients when we have finished the session to help us to modify and update our approach. We find that the sessions differ week to week and the patients very much benefit from discussing their anxieties with other people going through the same procedure. We have also noticed that if people have attended the same group and are in-patients at the same time they appear more relaxed and confident about the whole process. They also feel more relaxed and comfortable meeting the physiotherapist again when the real post-operative process begins – “Getting out of bed for the first time”. We certainly feel this group session has benefitted not only the patients but the Occupational Therapy and Physiotherapy team. Moving forward our plans are to facilitate people who fall out of our catchment area for equipment and extra support, and we will have more time to be able to help with this by identifying problems early enough to enable us to refer our patients to the appropriate services.

Occupational therapy involvement with adults undergoing a total hip

replacement takes place in the acute inpatient or pre- operative

setting, although not exclusively (Drummond et al 2012). Given the

wider context of the ‘service user flow’ (Figure 1), it is,

therefore, important to draw attention to the person- centred and

holistic philosophy of occupational therapy

Wainwright T. and Middleton R. An orthopaedic, enhanced recovery pathway. Current anaesthesia and critical care 2010


Appendix 1 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month Audit Programme v5.0 2012/13 Hospital Name: Implemented: July 2012

Authors: R. Saunders / A. Shannon / N. Carre For review: June 2013

Use arrow symbol to locate required audit

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

Anaesthetic Standards98% 99.6%

Medical Records98% VTE 60%

86%

Det Pt 100% VTE 55%

N & H

90% 100% VTE 85%

Det Pt

92% 100% VTE 95% N & H

Consent100% 98% 100%

Green 100%

Discharge97% 100%

Cool

Amber 90 - 99%

Care Pathways and Variance

Tracking 79% 90%Amber 80 - 89%

Controlled Drugs95% 97% 100%

Hot

Amber70 - 79%

Prescribing97% 92%

Red 69% and under

Medicines Management90% 87%

Radiology100% NA 100% na 99% na

Physiotherapy91%

Records

99%

Service

Standard

96%

Records

CPD

100%(on

going)

Theatre97%

Infection Prevention and

Control*

Hand

hygiene

100%

NA

Isolation

100%

PVCCB

UCCB

98% SSI 97%

Hand

hygiene

99%

CVCCB

N/A SSI 99%

na to be

rep;aced

by

Hand

hygiene

98%

98%PVCC

B UCCB

Infection Prevention and

Control - Environmental

Audit

99%

Environ

Environ

95%

Environ

97%

99%

Environ

TransfusionComplian

ce 94%

Allogeneic

Traceabilit

y 100%

Autologo

us

Traceabili

PVCCB = Peripheral Venous Catheter Care Bundle

Copyright © 2012 Ramsay Health Care UK

VTE = Venous Thromboembolism

Det Pt = Deteriorating Patient

UCCB = Urinary Catheter Care Bundle

Traffic light score

*Key:

CVCCB = Central Venous Catheter Care Bundle

SSI = Surgical Site Infection

PEAT = Patient Environment Action Team

N&H = Nutrition and Hydration


Appendix 2 – CQUIN Schedule

1.1 The summary of goals table in Schedule 18 Part 2 (Commissioning for Quality and Innovation (CQUIN)) shall be deleted and replaced

as follows:

“Summary of goals1

Goal Number

Goal Name Description of Goal Goal weighting (% of CQUIN scheme available)

Quality Domain (Safety, Effectiveness, Patient Experience or Innovation)

1 VTE VTE Risk Assessment 0.166% Safety

2 Patient experience

Composite Indicator on responsiveness to personal needs

0.166% Patient Experience

3 NHS Safety Thermometer

Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter, and VTE

0.166% Safety and Effectiveness

4 Service Transformation

Alternative to face-to-face contact 0.5% Innovation

5 Pain management

Pain management following surgery 1.5% Patient Experience

Totals: 2.5%


Local contract ref. INDEPENDENT 1

Goal number 1

Goal name VTE

Indicator number 1

Indicator name VTE risk assessment

Indicator weighting (% of CQUIN scheme available)

0.17%

Description of indicator % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool

Numerator Number of adult inpatient admissions reported as having had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool (including those risk assessed using a cohort approach in line with published guidance - http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117030.pdf)

Denominator Number of adults who were admitted as inpatients (includes day cases, transfers and elective admissions)

Rationale for inclusion VTE is a significant cause of mortality, long-term disability and chronic ill health. It was estimated in 2005 there were around 25,000 deaths from VTE each year in hospitals in England and VTE has been recognised as a clinical priority for the NHS by the National Quality Board and the NHS Leadership Team. Reference: DH 2010 Using the Commissioning for Quality and Innovation (CQUIN) payment framework - Guidance on national goals for 2011/12. page 8

Data source monthly data return through Unify2

Frequency of data collection real time (on admission)

Organisation responsible for data collection

Provider

Frequency of reporting to commissioner Provider to submit a mandatory monthly data return through Unify2

Baseline period/date N/A

Baseline value N/A


Final indicator period/date (on which payment is based)

31 March 2013

Final indicator value (payment threshold)

95%

Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner)

95% monthly

1/12 Payment will be made for each month the unit achieves 95%.

Final indicator reporting date 20 working days after the end of each month (deadline for Unify2 submission)

Are there rules for any agreed in-year milestones that result in payment?

No

Are there any rules for partial achievement of the indicator at the final indicator period/date?

No



Goal number 2

Goal name Patient experience - personal needs

Indicator number 2

Indicator name Composite indicator on responsiveness to personal needs


0.17%

Description of indicator The indicator will be a composite, calculated from 5 survey questions. Each describes a different element of the overarching theme: “responsiveness to personal needs: • Involved in decisions about treatment/care • Hospital staff available to talk about worries/concerns • Privacy when discussing condition/treatment • Informed about medication side effects • Informed who to contact if worried about condition after leaving hospital

Numerator Composite score reflecting the following responses to the 5 questions within the indicator as follows 1) Involvement in decisions about treatment/care “yes definitely” 2) Hospital staff being available to talk about worries/concerns “yes definitely” and “I had no worries or fears”

3) Privacy when discussing condition/treatment “yes always” 4) Being informed about side effects of medication “yes completely” and “I did not need an explanation” 5) Being informed who to contact if worried about condition after leaving hospital “yes” The composite indicator is determined by taking the total of the above responses to the 5 questions and dividing this by 5.


Denominator N/A

Rationale for inclusion The indicator incorporates questions which are known to be important to patients and where past data indicates significant room for improvement across England. Reference: DH 2010 Using the Commissioning for Quality and Innovation (CQUIN) payment framework - Guidance on national goals for 2011/12. page 22 Ramsay Health Care: Confidential Patient Questionnaire Ramsay Health Care: We value your opinion (patient feedback and complaints guide)

Data source Adult inpatient survey, from the CQC nationally coordinated patient survey programme. The survey is conducted annually between October and January for patients who had an inpatient episode between July and August.

Frequency of data collection Annually


Provider

Frequency of reporting to commissioner Annually. Provider will supply Commissioner with advance data supplied by the national survey coordination centre in February 2013.

Baseline period/date

Baseline value A composite value of the five survey questions/responses of 80.00


Adult inpatient survey 2012 (based on inpatient episodes between July and August 2012)


Composite score of ≥98% of the baseline value (80.00) will result in payment of 100% of the CQUIN value


Payment will be based on the provider having achieved the final indicator value through the survey results

Final indicator reporting date 01/03/2013


No



Yes

Rules for partial achievement at final indicator period/date (only complete if the indicator has rules for partial achievement at final indicator period/date)


% of CQUIN scheme available

Achievement of ≥95% but < 98% of the indicator

75.00%


67.00%


33.00%

Achievement of <80% of the indicator 0.00%


Goal number 3

Goal name SAFETY THERMOMETER

Indicator number 3

Indicator name Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter, and VTE


0.17%


Description of indicator This CQUIN incentivises the collection of data on patient harm using the NHS Safety Thermometer harm measurement instrument (developed as part of the QIPP Safe Care national work stream) to survey all relevant patients in all relevant NHS providers in England on a monthly basis Detailed information on the appropriate patients and relevant settings for use of the NHS Safety Thermometer are defined in the NHS Safety Thermometer guidance for use. The intention is for all NHS-funded providers, across community, mental health, acute and residential and nursing care, including NHS-funded independent sector providers, to use the Safety Thermometer, apart from where exceptions apply, as detailed in the guidance. This will allow nationally consistent data to be collected and published as well as facilitating local improvement activity. Where providers already have in place existing data collections that duplicate the measures in the tool, commissioners should use this CQUIN to incentivise transition to the safety thermometer tool to ensure data is produced that is consistent with the national collection. All relevant providers will be expected to have begun use of the national Safety Thermometer measurement tool by the end of 2012/13. Use of the Safety Thermometer will be mandatory in 2013/14. Where organisations are already submitting full data for the safety thermometer and there is no room for further improvement, commissioners should consider increasing the proportion of CQUIN payments available for the other national CQUIN goals.

Numerator Number of months per quarter for which a complete record of Safety Thermometer survey data covering all appropriate patients in all appropriate settings for all relevant measures is submitted.

Denominator Total number of relevant months in the quarter (usually 3).

Rationale for inclusion Participation in data collection using the NHS Safety Thermometer is an important preparatory step for NHS-funded provider organisations in reducing harm. Incentivising use of the NHS Safety Thermometer will increase the participation in this data collection, establish a national baseline of performance on the four harms and provide information on the range of performance. This will allow the establishment of quality improvement aims for year two (further details to follow) and contribute to the provision of data required for the Outcomes Framework and Government Transparency Agenda. The intention is that further improvement goals relating to outcomes measured by the Safety Thermometer will be incentivised in future years.


Data source Data is from two primary sources according to the NHS Safety Thermometer guidance: a physical examination of the patient (including a conversation with them or their carer) and nursing / medical records (including pharmacy records). Further information will be provided in due course on how to submit data.

Frequency of data collection Data will be collated locally using the NHS Safety Thermometer tool on a single day per month (day to be determined locally in each provider). This monthly data will be uploaded by each provider to the NHS Information Centre on a quarterly basis (i.e. data representing the 3 constituent months in a single quarter uploaded to the IC quarterly) Further information will be provided in due course on how to submit data.


Provider

Frequency of reporting to commissioner Quarterly - reporting use of NHS Safety Thermometer will be through direct submission of the data to the Information Centre. The commissioner will use the data published by the Information Centre to review performance for each relevant Quarter.

Baseline period/date Not applicable. The CQUIN incentivises correct use of the Safety Thermometer and therefore no baseline performance applies.

Baseline value Not applicable. The CQUIN incentivises correct use of the Safety Thermometer and therefore no baseline performance applies.


April 2012 to March 2013

Final indicator value (payment threshold) Three consecutive quarterly submissions of monthly survey data for all relevant patients and settings using NHS Safety Thermometer will trigger full payment of the CQUIN.



Each set of complete data for a single Quarter will qualify the provider for 33.3% of the total value for this CQUIN (given only 3 quarters of 2012/13 are in scope). Commissioners will satisfy themselves of the appropriate completion and submission of the data collection for each provider by reference to the Information Centre’s publication of Safety Thermometer results for each provider. Further clarification on completeness of data submission (for example related to patient exclusion data) should be obtained from the relevant provider if necessary This CQUIN will require monthly surveying all appropriate patients (as defined in the NHS Safety Thermometer guidance) to collect data on four outcomes (pressure ulcers, falls, urinary tract infection in patients with catheters and VTE). Experience to date suggests data is best collected at the point of care by healthcare professionals (in accordance with guidance) using a point prevalence survey method (one day per month), entered into the instrument by administrative staff and aggregated at organisation level by performance teams or other suitable staff. Data should be submitted to the Information Centre quarterly. A completed Safety Thermometer survey for all relevant patients must be included for each month in the relevant quarter’s submission to trigger payment.

Final indicator reporting date 30 working days after the end of the period


No


Yes


Final indicator value (payment threshold) % of CQUIN scheme available Submission of partial data for a single quarter (1 or 2 months) will attract no payment

0.00%


Submission of data representing 3 surveys for the 3 consecutive months in a single quarter will trigger 33.3% of the yearly total possible payment

2.00%

Submission of data for 2 complete quarters will trigger 66.6% of the total possible payment.

4.00%



Goal number 4

Goal name Service Transformation

Indicator number 4

Indicator name Alternative to face to face contact


0.5%

Description of indicator Transition and Implementation of alternative solutions to outpatient(OP) follow ups, reducing 'face to face' contacts

Numerator Number of face-to-face contacts for followup appointments

Denominator Total number of patient follow ups

Rationale for inclusion ‘Innovation, Health and Wealth’ (DH, 2011) identified that over £300million is spent nationally on bringing patients back to Out Patients for appointments for a 'negative result'* (definition to be agreed). The commissioner proposes to drive patient quality forward by reducing the numbers of patients attending an outpatient follow up for a 'negative' appointments (e.g. wound healed, no pain, benign, blood results negative, no follow up) through the use of ‘alternative’ follows up, where it is right and safe to do so. agreed pathways (speciality identified) and clinical engagement of provider identified systems and solutions to facilitate this change is required.

Data source HES/SUS

Frequency of data collection Monthly


Provider

Frequency of reporting to commissioner Quarterly (with monthly split)

Baseline period/date 30 April 2011 - 31 March 2012

Baseline value First milestone - Ramsay to provide a proposal to the PCT by 6th June, final agreement of reduced follow up ratio for Q2-Q4 by 30th June.


31-Mar-13


Final indicator value (payment threshold) TBC% reduction in the rate of face-to-face follow-up contacts * rate to be agreed at Q1


Specialties procedures and patient criteria as well as targets / trajectories to be agreed as part of Q1 implementation plan approval

Final indicator reporting date 20 working days after the end of each quarter


Yes


No

Milestones (only complete if the indicator has in-year milestones)

Date/period milestone relates to Rules for achievement of milestones (including evidence to be supplied to commissioner)

Q1 baseline data and implementation plan

Quarter 2 onwards rate TBC of reduction in face-to-face follow up contacts



Goal number 5

Goal name Pain Management

Indicator number 5

Indicator name Pain Management


1.5%

Description of indicator To proactively help patients with pain management following surgery.

Numerator Ramsay Healthcare Local Survey of all admitted patients to include questions:- Were you ever in pain? Did staff do everything possible to control your pain? Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?

Denominator N/A

Rationale for inclusion Improve the patient experience and reduce pain following surgery

Data source Ramsay Healthcare Local Patient Survey

Frequency of data collection Monthly



Frequency of reporting to commissioner Quarterly (with monthly split)

Baseline period/date N/A

Baseline value N/A


31-Mar-13

Final indicator value (payment threshold) 60% Response rate 90% Yes to Question 1 95% Yes to Question 2


Achieve 60% response rate to patient survey each quarter. Q. Do you think the hospital staff did everything they could to help control your pain? Target = 90% Yes definitely Q.Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand? Target = 95% Yes completely

Final indicator reporting date 20 working days after the end of each quarter



No


Yes


Final indicator value (payment threshold) % of CQUIN scheme available 60% response rate each Quarter 33.33%

Do you think the hospital staff did everything they could to help control your pain? Target = 90% Yes definitely each Quarter

33.33%

Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand? Target = 95% Yes completely each Quarter

33.44%


Clifton Park 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:

01904 464 550 www.cliftonparkhospital.co.uk

Neurological Centres

Documents

Clifton Park Hospital - NHS