New Hall Hospital - NHS...Helen White Regional Director, Ramsay Health Care UK Commissioner/PCT and other external bodies . Quality Accounts 2011/12 Page 7 of 36 Welcome to New Hall

New Hall Hospital Quality Account 2012/13

Extraordinary care needs extraordinary people

Quality Accounts 2011/12 Page 2 of 36

Contents Introduction Page

Welcome to Ramsay Health Care UK and New Hall Hospital

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 2012/13 (looking back)

2.1.2 Clinical Priorities for 2013/14(looking forward)

2.2 Mandatory statements relating to the quality of NHS services provided

2.2.1 Review of Services

2.2.2 Participation in Clinical Audit

2.2.3 Participation in Research

2.2.4 Goals agreed with Commissioners

2.2.5 Statement from the Care Quality Commission

2.2.6 Statement on Data Quality

2.2.7 Stakeholders views on 2012/ 13Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 Patient Safety

3.2 Clinical Effectiveness

3.3 Patient Experience

Appendix 1 – Services Covered by this Quality Account

Appendix 2 – Clinical Audits


Welcome to Ramsay Health Care UK New Hall 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)


Introduction to our Quality Account This Quality Account is New Hall 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 review 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. In 2009/10 the Quality Account was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and centre within the Ramsay Health Care UK. It was recognised, however, 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 developed its own Quality Account for 2010/11 and this account for 2012/13 is New Hall Hospital’s third submission.


Part 1 1.1 Statement on quality from the General Manager Fiona Taylor, General Manager, New Hall Hospital Welcome to The New Hall Hospital third quality account. This report outlines the Hospitals approach to quality improvement, progress made in 2012/13 and plans for the forthcoming year. New Hall 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. As well as being treated quickly and safely, 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 2012/13 we have made a raft of improvements to ensure 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 our hospital. In addition, it shows how our values, combined with our priorities, are improving the way in which we treat our patients. For example, we continue to have a very low infection rate within our units and submissions to Surgical Site Surveillance Service has commenced. Our surgical site infection rates are significantly lower than the national average. Fiona Taylor General Manager


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. Fiona Taylor General Manager New Hall Hospital Ramsay Health Care UK This report has been reviewed and approved by: Mr David Chapple, Consultant Spinal Surgeon Medical Advisory Committee Chair Mr Peter Guy, Consultant Urologist Clinical Governance Committee Chair Helen White Regional Director, Ramsay Health Care UK Commissioner/PCT and other external bodies


Welcome to New Hall Hospital

• New Hall Hospital is an independent hospital delivering a full range of specialist

surgical and medical services. The hospital is set in beautiful grounds and the original Georgian manor House now accommodates three theatres and 43 beds with excellent physiotherapy and radiology services. 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 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.

• We provide fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of 18 years or 16 if private), whether medically insured, self-pay, or from the NHS).

• We deliver a full range of specialist surgical and medical services (excluding cardiac and neurosurgery) to include orthopedics, spinal, ENT, gynecology, urology, colorectal, breast and cosmetic surgery and general medicine.

• Patients requiring level 2 critical care are treated and cared for by appropriately trained staff in a dedicated high dependency unit. All Ramsay Health Care UK hospitals have transfer arrangements in place with their local trust or critical care network for level 3 care.

• In 2012/13 we treated a total of 5470 patients. 3689 NHS patients (68%) and 1792

private patients (32%). • We currently employ

Consultants (directly employed by Ramsay) 4 Consultants (with practicing privileges) 100 (all specialities)

Registered Nurses 51 + 11 bank Operating Department Practitioners 9 + 3 bank Radiographers 3 + 4 bank Physiotherapists 4 + 4 bank Health Care Assistants 13 + 1 bank Other Support Staff 27 + 3 bank

Administrative staff 49 + 12 bank • The staff to patient ratio is 1:between 5 and 8 (depending on patient dependence

and there is an experienced Residential Medical Officer (RMO) on site 24 hours a day

• We provide an outreach service for outpatient NHS patients at Poole Hospitals and Blandford clinic for spinal and orthopedic services.

• 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 have a dedicated GP liaison officer who has close contact with both the practice managers and the GPs at practices throughout Wiltshire, Hampshire and Dorset. She visits GP practices and organises regular “Lunch and Learns” and


breakfast meetings taking Consultants into GP surgeries to offer training. In addition she also runs regular Consultant led open evenings for GP’s.

• We work closely with our local Clinical Commissioning Groups (Wiltshire, Hampshire, Dorset and Somerset to provide a range of surgical services within the standard acute contract.

• We work closely with the Salisbury District Hospital who provide us with blood transfusion, urgent pathology, histopathology and access to level 3 critical care services.


Part 2 2.1 Quality priorities for 2013/2014 Plan for 2013/14 On an annual cycle, New Hall 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 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. 2.1.1 A review of clinical priorities 2012/13

1. World Health Organisation (WHO) Surgical safety checklist – completion of the checklist is a key safety element for patients undergoing surgical procedures at New Hall. Accurate completion of the WHO checklist is audited regularly and the results are consistently over 90% compliance.

2. Venous Thromboembolism (VTE) risk assessment and Prevention New Hall hospital has established a robust policy to comply with Ramsay policy in order to reduce avoidable death, disability and chronic ill health from VTE. We have reduced the variance of prophylactic measures used at New Hall hospital in order to minimise human error and allow outcomes to be measured. The hospital has an excellent VTE risk assessment compliance record. Data submitted to UNIFY shows 97% achievement from April 12 to February 2013.


Data is 2012/13 - UNIFY VTE Submissions March data excluded as not available yet.

Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. From the core never events, there are 20 that affect Ramsay. • Wrong site surgery • Wrong implant/prosthesis • Retained instrument post-operation • Wrongly prepared high-risk Injectable medication • Maladministration of potassium-containing solutions • Wrong route administration of chemotherapy • Wrong route administration of oral/enteral treatment • Intravenous administration of epidural medication • Maladministration of Insulin • Overdose of midazolam during conscious sedation • Opioid overdose of an opioid-naïve patient • Fall from unrestricted window • Entrapment within bedrails • Transfusion of ABO incompatible blood components • Misplaced naso or oro-gastric tube not detected prior to use • Wrong Gas administered • Failure to monitor and respond to oxygen saturation • Air embolism • Misidentification of patient • Severe scalding of patients

Preventative measures have been implemented and there have not been any “Never event” incidents in this reporting year at New Hall hospital


3. Real time incident reporting – All incidents, complaints and clinical key performance indicators such as readmissions, reoperations, healthcare acquired infections etc. are entered onto the corporate risk management system (RISKMAN) in real time so trends can be analysed and identified promptly. This enables us to review events as they happen and prevent recurrence thus contributing to patient safety. The system was successfully implemented in July 2012

4. Cleanliness and infection prevention - There have been no MRSA bacteraemias

or C Difficle at the hospital over this reporting period. We screen all patients for MRSA prior to admission to New Hall and all staff have a mandatory requirement to undertake hand hygiene training. We maintain our regular audit programme which includes hand hygiene, urinary catheter and intravenous line care, and our cleaning standards and physical environment. We participate in the Health Protection Agency data collection for surgical site infections following hip and knee joint replacements and we have not had cause to report any infections to the HPA during the last year.

5. National Joint Registry (NJR) The purpose of the NJR is to define, improve and maintain a quality of care of individuals receiving hip, knee and ankle joint replacements across the NHS and independent healthcare sector. Shoulder and elbow replacements have also been added to the list in addition to those above. New Hall registers all patients undergoing this type of surgery with the NJR providing they consent to this. The consent rate and linkability for New Hall hospital 2012/13 is 90% against a key performance indictor of the NJR at 95%. The NHS number tracing rate requires improvement to ensure that patients can be traced easily and information from different providers can be collated. All staff that input the data have been informed how to ensure NHS number tracing can be achieved to achieve a 100% traceability rate. The NJR has been instrumental in the recall of Metal on Metal hip replacements and New Hall has implemented all the actions required to maintain a safe and appropriate service in relation to this.


6. Clinical training – New Hall hospital will continue to ensure that patients are cared for by safe and competent staff. Providing quality care for patients is a high priority at New Hall Hospital and all relevant clinical staff will be supported through training and protected time to achieve competency level education. This year the staff have undertaken competency based training in “recognising the signs of the deteriorating patient” based on early warning scoring and trigger tools. The critical care training remains competency based and all staff are expected to achieve competencies in infection prevention and control which includes hand hygiene. ILS and/or ALS training is mandatory for all clinical staff working in acute areas and this year we are also providing AIM (Acute Illness Management) training. Blood transfusion competencies – in line with patient safety we will ensure that blood transfusions or blood products are only handled/administered by competent trained staff.

7. Vulnerable adult/Child Protection, Mental Capacity Act, Deprivation of Liberty- New Hall hospital takes its responsibility for safeguarding vulnerable members of society seriously. We provide in house training and easy to use flowcharts for help and advice. These are available in all areas. All staff working within the hospital are required to have an enhanced CRB check andhave undergone mandatory training in vulnerable adult/child protection, with the lead nurse for child protection undergoing level 2 child protection training. Relevant staffs have also undergone training in the Mental Capacity Act and Deprivation of Liberty although neither have had to be used in this reporting period. Equality, diversity and human rights are a theme running through Ramsay Health Care. The organisations integrated governance framework, Group policies and practice comply with current legislation. To date there have not been any safeguarding incidents to report at New Hall Hospital.

8. Information Security-New Hall Hospital was re audited in March 2013 and achieved Information Security accreditation ISO270001.

9. Staff satisfaction survey-Ramsay undertake an annual staff survey to measure staff satisfaction as it is well known that satisfied, well trained and competent staff will contribute to reducing patient safety risks. New Hall is bench marked against other Ramsay UK units.


South Region New Hall

Overall 4.50 4.44 Leadership 4.30 4.51 My Company 5.16 5.13 My Manager 4.71 4.49 My Team 5.02 4.74 Personal Growth 4.87 4.94 Fair Deal 3.80 3.59 Giving Back 3.80 3.65 Wellbeing 4.36 4.48

2.1.2 Clinical Priorities for 2013/14 Patient Safety • Surgical safety checklist – compliance to the checklist will remain an ongoing

quality initiative at New Hall. • Bar coding for patient identity bands – this priority has been on hold awaiting a

formal notice for implementation. However, this is still on Ramsay’s agenda and will be introduced as it is still considered best practice and will prepare us for many patient care initiatives which will require patients to have a barcode on their wristbands.

• Venous-Thromboembolism assessment – will remain an ongoing quality initiative

and we will continue to audit our compliance to risk assessment and appropriate prophylaxis. Audit results will be submitted as one of the nationally mandated quality indicator.

• Never events - preventing the occurrence of any serious, largely preventable patient

safety incidents that should not occur will remain a clinical priority for 2013/14. • National Joint Register – New Hall aims to maintain its consistently good scores for

data submission to the National Joint register.

• JAG accreditation-One of New Hall priorities for the year is to achieve this nationally recognised award. We have appointed a lead nurse for endoscopy and set up an Endoscopy user group to facilitate this. We submit date for the Global Rating Scale (GRS) and will be inspected to assess compliance with JAG in February 2014.

• Clinical training – New Hall hospital will continue to ensure that patients are cared

for by safe and competent staff. Providing quality care for patients is a high priority at New Hall Hospital and all relevant clinical staff will be supported through training and protected time to achieve competency level education.

• Blood transfusion competencies – in line with patient safety we will ensure that

blood transfusions or blood products are only handled/administered by competent trained staff.


• Safeguarding of children and vulnerable adults– the hospital takes its

responsibility for safeguarding vulnerable members of society seriously. We will continue to provide training and easy to use flowcharts for help and advice. These are available in all areas and will assist staff in accessing timely and appropriate manner. All staff working within the hospital are required to have an enhanced CRB check.

• Staffing – to ensure that adequate numbers of skilled staff are available to care for

our patients staff rotas are prepared in advance and all departments in the hospital have their own bank of staff to provide additional cover as required. This year Ramsay have invested in an electronic rostering system called Allocate. The system will reduce the time spent on producing numerous rotas throughout the hospital and will be accessible to all staff so they can log in and make requests for leave, training etc. It is also designed to record training hours and remind staff when they need to attend mandatory training sessions. The system will be set to produce rotas in line with patient numbers and specific skill mix requirements.

Clinical effectiveness Ambulatory Day Care – better outcomes and improving patient experience Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both medical and surgical) to hospital for a planned procedure, returning home the same day i.e. the patient does not incur an overnight stay) Over recent years, partly due to medical advances the number of day surgery patients has increased compared to those requiring inpatient care. In 2012 the percentage of day surgery patients we treated was 67%. We need to ensure that our hospital facilities and patient flows better meet the case mix we now deliver. We will aim to ensure that 90% of all day care patients are treated in our ambulatory care facilities. In order to do this and provide our patients with a more efficient patient pathway through the hospital, we have separated the day surgery patients from our inpatients by the development of an ambulatory care unit. Best practice has shown that by doing this, patient care will improve as waiting time and recovery period are reduced. We will monitor the efficiency and effectiveness of the ambulatory care unit through amending our coding system, management accounts and by patient satisfaction questionnaires. The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for Innovation and Improvement (2008). It focuses on the way ward teams work together and organise themselves, in order to reduce the burden of unnecessary activities, and releasing more time to care for patients in a reliable and safe manner within existing resources. The approach is very much ‘bottom up’ with all ward staff suggesting ideas and ways in which they could improve their environment and processes. The Productive Ward project has been implemented at New Hall and is an ongoing project. The project aims to improve inefficiencies with the ward environment releasing staff to care for the patients. The ward utility rooms have been reorganised and labelled so items are easier to find and equipment used on a regular basis (e.g. Dinamaps) always returned to the same place when not in use so they can be found easily.


Group pre assessment – New Hall pre-assessment and physiotherapy team have implemented a group pre assessment process for all spinal surgery. It was recognised that seeing each patient individually was not always the most efficient way of giving the required pre-operative information to patients and that holding group sessions encouraged discussion and group interaction. The patients are first assessed at time of consultation to ensure they are fit for surgery and then they are invited to attend a group session where they are given a procedure specific presentation by the physiotherapist and/or spinal nurse practitioner and an opportunity to ask questions and meet other patients having the same procedure. The group session is followed up by an individual assessment by the spinal nurse practitioner. Ramsay Health Care is a member of Private Hospitals Information Network which enables providers to benchmark against other providers for key performance indicators. Improve National benchmarking – it was recognised that we needed more transparency between ourselves and other independent sector providers/the NHS in order to monitor and improve our services. This is even more important now we are working in partnership with the NHS. We will be benchmarking in the following areas; VTE risk assessment compliance – benchmarking through the national stats website. Link; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH122283 PROMS results – benchmarking through national PROMS website. Link: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID-1295 Patient experience – informing patient choice Patient Reported Outcomes Studies (PROMs)- We continue to monitor the national PROMs results for Hip, Knee, Varicose Veins and Hernia surgery by offering all patients who undergo this type of surgery the opportunity to complete a questionnaire before and after surgery to monitor an improvement in their quality of life. Encouraging their use in identifies poor outcomes and allows us to review practice where necessary. We share the results with Surgeons and physiotherapists and encourage them to use them to review their practice by meeting and discussing the results with their teams and benchmarking against other sites. We are expanding our use of PROMS surveys to cover more procedures to enable better understanding of treatment outcomes from the patients view point. We have recently implemented PROMS for spinal surgery using the British Spinal Registry. Patient satisfaction survey – New Hall has always achieved a high level of patient satisfaction, the most recent Ramsay inpatient survey was carried out between January and August 2012. It uses a mean rating score following the approach of the Care Quality Commission which allows it to be benchmarked against 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) and 100 (most positive)


In response to the question, Overall, how would you rate your experience, New Hall scored 90% We also undertake an external on line survey run by QA that sends a questionnaire to a proportion of patients who have received care at New Hall. All patients are given a “we value your opinion” leaflet on discharge and asked to take the friends and family test which is where they say whether they would recommend the hospital to their friends and family.


1.2 Mandatory Statements

2.2.1 Review of Services During 2012/13 New Hall Hospital provided NHS services. New Hall 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 in 1 April 2012 to 31st March 2013 represents 100 per cent of the total income generated from the provision of NHS services by the New Hall hospital for 1 April 2012 to 31st March 2013 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 Health care Assistant (HCA) Hours as % of Total Nursing (81% qualified to 19% HCA) Agency Hours as % of Total Hours (0.54%) % Staff Turnover (12.8%) % Sickness (3.99%) Total Lost Worked Days (1602) Patient Formal Complaints per 1000 HPD's (4.2) Number of Significant Clinical Events (1) Quality Infection Control Audit Score (94%) Readmission per 1000 Admissions (2%)


2.2.2 Participation in clinical audit Between 1st April 2012 to 31st March 2013 New Hall Hospital participated in two national clinical audits and no national confidential enquiries The national clinical audits that New Hall Hospital was eligible to participate in during 1st April 2011 to 31st March 2012 are listed in the table below; National Clinical Audits Participation % submitted NJR Yes 100 Elective surgery (PROMS) Yes 100 Local Audits The reports of 63 which includes 16 infection prevention and control, 3 transfusion, 4 physiotherapy and 8 radiology local clinical audits from 1 April 2012 to 31st March 13 were reviewed by the Clinical Governance Committee and show good compliance to national standards. Where is action is required, actions plans are developed and implemented with review in timeframes set. The audit schedule can be found in appendix 2 2.2.3 Participation in Research There were no patients recruited during 2011/12 to participate in research approved by a research ethics committee. 2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework New Hall hospitals income for achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework is applicable from 1st April 2012 (SAC commencement) to March 31st 2013. We are confident of achieving our locally agreed CQUINs and all the nationally mandated CQUINS. New Hall has agreed revised CQUINs for 13/14 and we are currently waiting for them to be signed off. 2.2.5 Statements from the Care Quality Commission (CQC) New Hall Hospital is required to register with the Care Quality Commission and its current registration status on 31st March 2013 is registered without conditions.. The Care Quality Commission has not taken enforcement action against New Hall Hospital during 2012/13 New Hall Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. New Hall had an unannounced inspection on 21/01/2013. The outcomes inspected were 1, 4, 8, 13, and 16. New Hall was found to be fully compliant.


2.2.6 Data Quality Statements NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2012/13 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: The patient’s valid NHS number: • 99.98% for admitted patient care; • 99.95% for outpatient care; and • 0% for accident and emergency care (not undertaken at Ramsay hospitals). The General Medical Practice Code: • 99.99% for admitted patient care; • 99.99% for outpatient care; and • 0% for accident and emergency care (not undertaken at Ramsay hospitals). 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/ Clinical coding error rate New Hall Hospital is subject to payment by results clinical coding audit and will be audited as a company in 2013. The clinical coding error rate in 2012 was 13.29% but an action plan has been put in place to address the issues raised.


2.2.7 Stakeholders views on 2012/13 Quality Account The regulations require you to send copies of your Quality Account to your relevant Local Involvement Network (LINk), Overview and Scrutiny Committee (OSC) and lead Clinical Commissioning Groups for comment prior to publication, and you should include these comments in the published Quality Account here:


Part 3: Review of quality performance 2012/2013

Statements of quality delivery Matron, Deborah Stott Review of quality performance 1st April 2012 - 31st 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

NICE / Safety guidance Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by the NHS Commissioning Board Special Health Authority. Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that are applicable to our business and thereafter monitoring their implementation. 3.1 Patient safety We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety. Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators. Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below.


3.1.1 Infection prevention and control New Hall hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 4 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:

• New Hall has an in house infection control team led by an infection control link nurse involving staff members from every department and a Consultant Microbiologist from the local trust. The infection control team meet bi monthly to review all aspects of infection control including audits, training, infection control issues etc. Infection control is mandatory for all staff and is part of the Ramsay e learning programme. In addition to the mandatory training the infection control link nurse carries out hand washing training and audits as per the infection control audit programme as seen in appendix 2. The results of all audits are discussed at infection control meetings, the Clinical Governance Committee and Heads of Department meetings.


As can be seen in the above graph our infection control rate has decreased from 20 to 17 over the last year. All of these cases were successfully treated with antibiotic therapy. There have been no cases of MRSA Bacteraemia The graph below gives the % of infections per 100 discharges

3.1.2 Cleanliness and hospital hygiene We continue to assess the hospitals facilities to ensure that we are providing a safe environment and use the following audit tools: Corporate - Environmental Audit – Quarterly Corporate - Health, Safety & Facilities Audit – Annually Patient Led Assessment of the Care Environment (PLACE) replaced Patient Environment Action Team (PEAT) audit. PLACE audit completed in May 12 awaiting results. Environmental Audit This audit was introduced in 2010, these are completed quarterly, the aim of this audit is to ensure a safe environment for all staff and patients, the objectives are: 1. To identify users and user groups 2. To advise on infection control issues arising 3. To acknowledge


The audit consists of an inspection of the hospitals clinical areas and includes the general environment, clinical equipment, decontamination, clinical practices, sharps handling, waste disposal and hand washing. New Halls environmental audit results were 90% in 2012/13. Health, Safety & Facilities Audit This audit, taken from Approved Codes of Practice (ACOPS) was introduced in 2009 and is completed annually. The standards are the minimum that an organization must adhere to ensuring a safe workplace. The benchmark set for 2010 was 90% and this has been raised to 95% for 2011. New Halls result for 2012 was 88%. The reason for this lower score was because of a lack of drawings for electrical and water services, biomedical equipment register incomplete and clinical and non clinical waste wasn’t segregated in one department. 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. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. New Hall has a Health & Safety committee that meets monthly to discuss all matters relating to health and safety and to review any adverse events that have occurred. All members of the health and safety committee have undertaken CIEH level 2 award in health and safety in the workplace . An audit of 10 steps to a safer site is carried out three monthly and there is a comprehensive system in place to test all equipment (facilities and medical). A slips, trips and falls action plan has also been implemented to reduce the number of patients falls. 3.2 Clinical Governance New Hall hospital has a Clinical Governance 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. The results highlighted in the graphs demonstrate the effectiveness of this approach over the last three years.


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 graph our returns to theatre rate has increased slightly in 2012/13 but remains low compared to the Ramsay average. The graph below gives the % of unplanned returns to theatre per 100 discharges.


3.2.2 Readmission to hospital Monitoring rates of readmission 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 and New Hall 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 graph our readmissions to hospital rate has decreased significantly year on year and is lower then the Ramsay average . The decrease may be as an improvement in post discharge written information and clearer explanations given to the patient.


The graph below shows the % of unplanned re-admissions per 100 discharges

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 Committtees for discussion, trend analysis and further action where necesary. 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: 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 Patient focus groups PROMs surveys Care pathways – patient are encouraged to read and participate in their plan of care Friends and family test


3.3.1 Patient Satisfaction Surveys Patient Perspective conducted an inpatient survey between January and August 2012. It uses a mean rating score following the approach of the Care Quality Commission which allows it to be benchmarked against 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) and 100 (most positive) The response rate for patients treated at New Hall mean was 73% Key questions and the mean rating score they attracted are shown below Did you have confidence and trust in the Doctors treating you? 99% Did you have confidence and trust in the Nurses treating you? 94% Were you given enough privacy when being examined/treated? 99% Overall, were you treated with respect and dignity? 97% 3.3.2 Patient Reported Outcome Measures (PROMs) New Hall Hospital participates in the Department of Health’s PROMs surveys for hip and knee surgery, hernias and varicose veins for NHS patients. The sample sizes are small and survey results are evolving. Indications so far are that New Hall Hospital patients report excellent outcomes, and results compare very favourably with other providers.


As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys specifically for private patients


Appendix 1 Services covered by this quality account Services offered as per Statement of Purpose

Services Provided Peoples Needs Met for: Treatment of Disease, Disorder Or injury

Bariatrics, Dermatology, General medicine, Neurology, Oncology, Paediatrics (outpatient consults only), Pain management, Physiotherapy, Psychiatry (outpatients only), Psychology, Orthopaedic medicine, Rheumatology, Sports Medicine Satellite Out patient services being carried out at Dorset County Hospital and Poole Hospital for Dorset PCT,

All adults 18 yrs and over, and young persons 16-18 yrs Children 0-16 yrs outpatient consultation only

Surgical Procedures

Bariatrics, Cosmetics, Dermatology, Ear, Nose and Throat (ENT), Gastrointestinal, General surgery, Gynaecology, Ophthalmic, Orthopaedic, Oral maxillofacial, Urological, Ambulatory, Day and Inpatient Surgery

All adults 18 yrs and over, young persons 16-18yrs excluding:

• 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 >340 (non bariatrics)

However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment.

Surgical Procedures

Bariatrics, Cosmetics, Dermatology, Ear, Nose and Throat (ENT), Gastrointestinal, General surgery, Gynaecology, Ophthalmic, Orthopaedic, Oral maxillofacial, Urological, Ambulatory, Day and Inpatient Surgery

All adults 18 yrs and over, young persons 16-18yrs excluding:

• 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 >340 (non bariatrics)

However, 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 screening

GI physiology, Imaging services, Phlebotomy, Endoscopy, Urinary, Urodynamics, Screening and Specimen collection Satellite Out patient services being carried out at Dorset County Hospital and Poole Hospital for Dorset PCT,

All adults 18 yrs and over, young person’s 3-18yrs


Appendix 2 – Clinical Audit Programme.


New Hall 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:

Fiona Taylor General Manager 01722 422333

www.newhallhospital.co.uk

Documents

New Hall Hospital - NHS...Helen White Regional Director, Ramsay Health Care UK Commissioner/PCT and other external bodies . Quality Accounts 2011/12 Page 7 of 36 Welcome to New Hall