Quality Account 2017/18€¦ · Quality Accounts 2017/18 Page 5 of 48 Introduction to our Quality Account This Quality Account is West Midlands Hospital’s annual report to the public

West Midlands Hospital Quality Account 2017/18

Contents

Introduction Page 3

Welcome to Ramsay Health Care UK 3

Introduction to our Quality Account 5

PART 1 – STATEMENT ON QUALITY 6

1.1 Statement from the General Manager 6

1.2 Hospital accountability statement 8

PART 2 11

2.1 Priorities for Improvement 11

2.1.1 Review of clinical priorities 2017/18 (looking back) 11

2.1.2 Clinical Priorities for 2018/19 (looking forward) 13

2.2 Mandatory statements relating to the quality of NHS services

provided 16

2.2.1 Review of Services 16

2.2.2 Participation in Clinical Audit 17

2.2.3 Participation in Research 19

2.2.4 Goals agreed with Commissioners 19

2.2.5 Statement from the Care Quality Commission 19

2.2.6 Statement on Data Quality 22

2.2.7 Stakeholders views on 2017/18 Quality Accounts 24

PART 3 – REVIEW OF QUALITY PERFORMANCE 27

3.1 The Core Quality Account indicators 27

3.2 Patient Safety 34

3.3 Clinical Effectiveness 38

3.4 Patient Experience 40

3.5 Case Study 42

Appendix 1 – Services Covered by this Quality Account

Appendix 2 – Clinical Audit Programme

Quality Accounts 2017/18 Page 3 of 48

Welcome to Ramsay Health Care UK

West Midlands 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 32 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 and, Clinical Commissioning Groups.

CEO and Director of Clinical Services Statements

Statement from Dr. Andy Jones, Chief Executive Officer, Ramsay Health Care UK

“The delivery of high quality patient care and outcomes remains the highest priority to Ramsay Health Care. Our clinical staff and consultants are critical in ensuring we achieve this across the whole organisation and we remain committed to delivering superior quality care throughout our hospitals, for every patient, every day. As a clinician I have always believed that our values and transparency are the most important elements to the delivery of safe, high quality, efficient and timely care. Ramsay Health Care’s slogan “People Caring for People” was developed over 25 years ago and has become synonymous with Ramsay Health Care and the way it operates its business. We recognise that we operate in an industry where “care” is not just a value statement, but a critical part of the way we must go about our daily operations in order to meet the expectations of our customers – our patients and our staff. Everyone across our organisation is responsible for the delivery of clinical excellence and our organisational culture ensures that the patient remains at the centre of everything we do. At Ramsay we recognise that our people, staff and doctors, are the key to our success and our teamwork is a critical part of meeting the expectations of our patients. Whilst we have an excellent record in delivering quality patient care and managing risks, the company continues to focus on global and UK improvements that will keep it at the forefront of health care delivery, such as our global work on speaking up for safety, research collaborations and outcome measurements.


I am very proud of Ramsay Health Care’s reputation in the delivery of safe and quality care. It gives us pleasure to share our results with you.” Dr. Andrew Jones Chief Executive Officer Ramsay Health Care UK


Introduction to our Quality Account

This Quality Account is West Midlands Hospital’s annual report to the public and other

stakeholders about the quality of the services we provide. It presents our achievements

in terms of clinical excellence, effectiveness, safety and patient experience and

demonstrates that our managers, clinicians and staff are all committed to providing

continuous, evidence based, quality care to those people we treat. It will also show that

we regularly scrutinise every service we provide with a view to improving it and ensuring

that our patient’s treatment outcomes are the best they can be. It will give a balanced

view of what we are good at and what we need to improve on.

Our first Quality Account in 2010 was developed by our Corporate Office and

summarised and reviewed quality activities across every hospital and treatment centre

within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in

depth information for the public and commissioners about the quality of services within

each individual hospital and how this relates to the local community it serves. Therefore,

each site within the Ramsay Group now develops its own Quality Account, which

includes some Group wide initiatives, but also describes the many excellent local

achievements and quality plans that we would like to share.


Part 1

1.1 Statement on quality from the General Manager

Welcome to West Midlands Hospital’s Quality Account, which I hope you will find both interesting and informative. Our Quality Account details the actions that we have taken over the past year to ensure that our high standards in delivering patient care remains our focus in everything we do. Through our comprehensive audit regime, listening to our stakeholders and our patients, we have been able to identify areas of good practice and where we can improve the care our patients receive. This has enabled us to refine some of our processes which have resulted in improvements in the patient experience and outcomes.

As the General Manager of West Midlands Hospital I am committed to ensuring that we deliver consistently high standards of care to all of our patients and I am pleased to have a team of engaged and passionate staff working with me to deliver our vision.

Our Vision;

‘As a committed team of professional individuals we aim to consistently deliver quality, holistic Inpatient and day-case services with exemplary customer care. We believe we are able to achieve this by continually updating our staffs’ skills and competencies. We strive to further develop our knowledge in order to deliver evidenced based clinical practice with patient care remaining our focus in everything we do.’

West Midlands Hospital is a long standing healthcare provider in the area. We offer a range of services to both private and NHS patients; ensuring patient care is at the centre of all that we do.

The team here all recognise that patients have a choice as to where they access their healthcare and it is pleasing to see that an ever increasing number of our local residents chose West Midlands Hospital as their hospital of choice last year. This is a testament to the efforts of the whole team working here and their commitment to delivering a positive experience.

Quality extends not only to the service we deliver to our patients but to our other customers – Consultants, GPs, Commissioners, other Trusts and by no means last, the people who work for, and with us. To understand how we deliver our services, and the quality standards we reach is critical in our understanding of where we can improve and how.

We have a strong track record as a safe and responsible provider, and our outcomes are shared with our private and NHS providers through regular meetings and reviews.

The experience that patients have in our hospital is of the utmost importance to us. As well as being treated safely and quickly, they must receive a personalised service, enhanced by good communication and a commitment to ensuring their privacy and


dignity are respected at all times. Our patient satisfaction responses via the Friends and Family reports at the time of writing this Quality Account, evidence a 99% rate for patients willing to recommend us to friends and family. At West Midlands Hospital we believe that each member of staff plays an important part in the success of the unit and will positively influence the personalised service we strive to offer. Regular training and development ensures best practice is delivered and our staff are trained and equipped to facilitate the best outcomes and experiences possible for every patient we care for.

Our workforce is very stable, with West Midlands Hospital having one of the lowest staff turnover rates in the organisation of 7.1% (in the previous 12 months) compared to 16.1% Ramsay overall . This reflects the value and recognition that our staff feel in their workplace here at West Midlands.

The Quality Accounts give all parties and providers access to quality activities and patient treatment outcomes at West Midlands Hospital. If you would like to comment or provide me with feedback then please feel free to contact me on the following number or via email;

Gloria Kerrigan,

General Manager,

West Midlands Hospital UK.

01384 560123 ext. 601 or E-mail [email protected]


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.

Gloria Kerrigan General Manager West Midlands Hospital Ramsay Health Care UK

This report has been reviewed and approved by:

Mr Raj Patel -Consultant General Surgeon and Honorary Senior, MAC Chair

Mr Neil Molony – Consultant ENT Surgeon, Clinical Governance Committee Chair

Dudley Clinical Commissioning Group


Welcome to West Midlands Hospital

West Midlands Hospital is one of the West Midland's leading private hospitals set in 3.5 acres of pleasant grounds at Colman Hill, Halesowen, ten miles from Birmingham City Centre. Operating since 1988 the hospital has 29 private bedrooms, all with en-suite facilities. We provide fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of 18 years), whether medically insured, self-pay, or from the NHS sector. Our Services West Midlands Hospital has two fully equipped theatres, 1 with Laminar flow; we have a dedicated endoscopy suite / minor ops theatre on the nursing floor. The ward has 29 inpatient beds all with en-suite facilities. The services offered at the hospital include the following specialties; Dermatology, ENT, Gastroenterology, General Medicine, General Surgery, Gynaecology, Nephrology, Neurology, Ophthalmology, Oncology (including Chemotherapy) Oral & Maxillofacial, Orthopaedics, Podiatry, Pain Management, Physiotherapy, Plastic Surgery, Radiology, Rheumatology, Urology, and Palliative Care. Diagnostic facilities include an imaging department with on-site X-ray, ultrasound, and Ramsay UK Diagnostics provides a mobile MRI and CT scanning service. Both our Physiotherapy and Radiology departments provide a direct referral service for self-pay patients, with the radiology service including ultrasound and general radiography. All of our services are Consultant delivered and are supported by clinical curse leads in key areas such as Oncology, Aesthetics, Endoscopy, Ward, Theatres and Out Patients. The Hospital also has a well-equipped outpatient department with 6 consulting rooms and a dedicated minor procedures area. The hospital is strictly regulated and audited by the Care Quality Commission, the governing body responsible for maintaining standards in healthcare, and the latest report can be found at:

www.cqc.org.uk

For the Year-to-date (1 April 2017 to 31st March 2018) West Midlands Hospital has seen

6,020 admissions.

Insured: 719 patients (11.9%)

Self-Pay: 577 patients (9.6%)

NHS: 4,724 patients (78.5%)

http://www.cqc.org.uk/


Our Staff

Currently, we employ a total of 110 contracted clinical and non-clinical staff members including: nurses, physiotherapists, radiographers, clinical support staff, administrators, operational management staff, hotel services, porters, receptionists and medical secretaries.

Senior Management Team

General Manager

Matron

Operations Manager

Finance Manager

We also have a Resident Medical Officer on site 24 hours a day seven days a week to support the consultant and nursing team delivering safe and effective care to all or patients.

NHS Partners & GP Communication

We work closely with our local CCG (Clinical Commissioning Group) at Dudley, to provide a range of surgical services under the Standard Acute Contract via the NHS e-Referral system. We offer direct referral services for private/self-pay/insured patients. All patients requiring NHS services are referred via their General Practitioner (GP) directly to the hospital. Our Pathology and Pharmacy services are provided by Dudley Group of Hospitals NHS Trust with whom we have a close working relationship. We provide educational sessions for GP practices, with the help of our consultant body and clinical staff. These individual lunch and learn style sessions are held at the GP practice for practice staff that wish to enrol. In addition to this, we supplement this by facilitating customer service / care sessions for administration teams via our two designated Customer Excellence representatives.

We also facilitate workshops specifically for practice administration staff, to support the NHS e-Referral processes. To further focus on our work with local GP’s and triage centres, we have a GP Liaison, whose key responsibility is to communicate and engage with our referring community.

Supporting Charity

As a hospital we look each year at supporting a charity, for 2017/18 we chose to support

a number of national and local Charities including Dudley MIND, St Richards Hospice,

SADs and Children In Need. We raised a combined total of over £9,000 for these

Charities through a number of different fundraising events including Raffles, participation


in the London Marathon; Wolf Run; Bicycle challenges; book sales and many other

events. We look forward to supporting other Charities and participating in fundraising

events in this coming year.

Part 2

2.1 Priorities for Improvement

On an annual cycle, West Midlands Hospital develops an operational plan to set

objectives for the year ahead.

We have a clear commitment to our private patients as well as working in partnership

with the NHS ensuring that those services commissioned to us, result in safe, quality

treatment for all NHS patients whilst they are in our care. We constantly strive to

improve clinical safety and standards by a systematic process of governance including

audit and feedback from all those experiencing our services.

To meet these aims, we have various initiatives on going at any one time. The priorities

are determined by the hospitals Senior Management Team taking into account patient

feedback, audit results, national guidance, and the recommendations from various

hospital committees which represent all professional and management levels.

Most importantly, we believe our priorities must drive patient safety, clinical effectiveness

and improve the experience of all people visiting our hospital.

Priorities for improvement

2.1.1 A review of clinical priorities 2017/18 (looking back)

1. Electronic Patient Record – i-Care Project

Ramsay Health Care UK started the process of upgrading and replacing its current PAS

(Patient Administration System) in 2015. The huge project continues and four Ramsay

UK Pilot sites went ‘Live’ in 2017.The next cohort of Ramsay UK sites have been

identified to commence roll out, however a date is yet to be finalised.


The new electronic system has been designed to include the following components;

Master Patient Index, Referral to Treatment pathways, outpatient and inpatient

management, case note tracking, clinical coding, ICPs, clinical noting, information

management and business analytics, dashboards and enablement for external

communications (SMS messaging, email, fax). Other features will include;

• Production of Discharge Summary letters – secure email

• Testing of Touch Screen Receptionist software

• Therapies (UDA and ICP’s)

• Clinical Portal – Overview of Patient

• Theatre Management

• Order Communications – Radiology (Carestream) and Pathology

examinations/tests (TDL) only

West Midlands Hospital will continue to keep this a priority for 2018-19 for our future roll

out. Staff are engaged in the process and regularly attend I-care team meetings held by

Head Office.

2. Training

West Midlands Hospital continued to be committed to support all staff in their continued

professional development in 2017. As previous years, staff were offered a number of

training opportunities such as; enrolling staff onto the corporate Mandatory training

programme, e-learning modules, offsite training days, accredited further education

courses, CPD courses and professional conferences.

The uptake was successful, with staff members completing ATP courses, ALS courses,

NVQ’s 1 & 2 and Leadership Programme (MBA qualification) amongst many other CPD

courses.

We will continue to support our staff in coming years, with a focus on Apprenticeships for

2018-19.


3. JAG Accreditation

This will be a continuation from last year as a clinical priority. The JAG Accreditation

Scheme is a patient centred and workforce focused scheme based on the principle of

independent assessment against recognized standards. The scheme was developed for

all endoscopy services and providers across the UK in the NHS and Independent Sector.

To achieve full JAG Accreditation an endoscopy service must provide clear evidence that

they have met all of the standards. The Endoscopy team and consultants have worked

very hard to ensure achievement of this standard and we will continue this work to

ensure we achieve re-accreditation in the future.

The West Midlands Hospital will have their JAG accreditation reviewed in 2019 and will

work on as a priority to ensure this is achieved again.

4. CQUINs

Each commissioner agrees a number of different CQUIN’s at the beginning of the

financial year with each of their providers. These include quarterly reviews of the

milestones set as well as final outcome targets. These are again a key Clinical focus for

2018 /2019. Please see section 2.2.4 for this year’s CQUIN Goals.

2.1.2 Clinical Priorities for 2018/19 (looking forward)

1 Patient Safety

Speak Up for Safety

This is a Ramsay wide programme that will be launched in July 2018 to change the

culture within Ramsay to improve patient safety.

To summarise, it is an evidence based approach to changing culture to promote

horizontal communication within Ramsay. It introduces the safety CODE which is a step

communication approach to give every individual the language skills and Ramsay

organisational support to voice concerns to identify in real time anything that may cause

potential harm to our patients.

The aim of the initiative is to provide a solid platform for building a culture of safety and quality, in which all staff and clinicians actively raise concerns, Cognitive Institute recommends implementing concurrently the Speaking Up for Safety and the Promoting Professional Accountability Programmes.


Speaking up is one of the most important ways of preventing unintentional harm. The Speaking Up for Safety Programme introduces Cognitive Institute’s Safety C.O.D.E.TM, a step-wise model to assist all staff to speak up for safety respectfully and easily. The programme also teaches that listening and welcoming others checking ensuring a positive safety culture is built. We look forward to commencing this at West Midlands Hospital in 2018, and sharing our progress and what we have achieved in next year’s report.

2 Patient Experience

Learning from Complaints & Incidents

Complaints:

The hospital has focused on learning from complaints, incidents and feedback from

patients in 2017/18. Now that this process is embedded, the hospital plans to further

develop and improve this work and the focus for 2018/19 is as follows:

Support departments to continue to learn lessons from complaints, to make improvements to the service offered to patients and their relatives.

SMT to monitor how well the hospital handles complaints and concerns to encourage improvement.

A local survey will be undertaken during 2018/19, to gauge how satisfied complainants are with the complaints process and their outcome. This information will form part of a review which will be shared with the Senior Management Team and Head of Departments on completion.

Ongoing review testing the effectiveness of the actions, to ensure the correct changes have been implemented, as a result of learning from complaints.

QIM/Matron to attend and complete the relevant private sector complaints resolution training co-ordinated by the Independent Sector Complaints Advisory Service.

Incidents:

West Midlands Hospital improved the way in which learning from incidents is shared last

year and will continue to do so in this coming year. West Midlands aims to provide a safe

environment for staff, patients and visitors by preventing harm. West Midlands Hospital

learns from incidents that occur to improve the quality and safety of our services and

facilities. It aims to develop and improve this learning by doing the following:


Deliver staff presentations at Bi-Monthly Lunch and Learn Seminars

Discussing incidents and learning from incidents in monthly departmental team meetings

Review Actions and effectiveness of action plans made as a result of incidents

Share learning from other organisations (where appropriate).

3 Clinical Effectiveness

Medicines Safety Thermometer

The Medicines Safety Thermometer is a national tool that has been designed to identify harm occurring from medication error. As a point of care survey it integrates measurement for improvement into daily routines and supports improvement in patient care. Data is collected on one day each month and enables wards, teams and organisations to understand the burden of medication error and harm to patients. Data can be used as a baseline to direct improvement efforts and then to measure improvement over time.

The Medication Safety Thermometer collects data on the following potential for errors/harms:

Medication Reconciliation (MR)

Allergy status

Medication omission

Omissions of Critical Medication

Identifying harm from high risk medicines

The Hospital has made significant progress with regards to medicines management

since the last CQC inspection back in 2015. The Hospital have established strong

working relationships with the local NHS Trusts Pharmacists, who will continue to audit

the medications activity within the hospital as part of the national clinical audit

programme. They will continue to feedback their findings, to ensure there is a safe and

effective practice regarding medication management. We are aiming for all our medicines

management audits to score consistently high – providing evidence that medicines are

handled safely here at West Midlands Hospital.

Part of this review will also incorporate training sessions for staff, dissemination of new

clinical guidelines purporting to medication safety and support where required to ensure

staff continue to have sound knowledge regarding medications management.


2.2 Mandatory Statements

The following section contains the mandatory statements common to all Quality Accounts

as required by the regulations set out by the Department of Health.

2.2.1 Review of Services

The West Midlands Hospital has reviewed all the data available to them on the quality of care in all of these NHS services.

During 2017/18 the West Midlands Hospital provided a total of 11 NHS services. The income generated from these NHS services represents 70.1% per cent of West Midlands Hospital’s total income from all provisions (1 April 2017 to 31st March 2018).

Ramsay uses a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year. The scorecard is reviewed each quarter by the hospitals senior managers together with Regional and Corporate Senior Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement.

In the period for 2017/18, the indicators on the scorecard which affect patient safety and quality were:

Human Recourses

Staff Costs as % Net Revenue 27.2%

HCA Hours as % of Total Nursing 17.4%

Agency cost as % of Total Clinical Staff Costs 13.3%

Ward Hours PPD 3.72%

Staff Turnover rolling 12 month % 8%

Sickness rolling 12 months % 3.93%

Lost time (includes annual leave, study leave and sick leave %

19.6%

Appraisal % 67%

Mandatory Training 86%

Staff engagement Score n/a

Number of significant staff injuries 1


Patient

Formal Complaints per 1000 HPD’s (Hospital Patient Days) 4.3

Patient satisfaction score 96%

Significant Clinical Events per 1000 Admissions 0.00002

Readmission per 1000 Admissions 0.00194

Quality

Workplace Health and Safety Score 94%

INFECTION CONTROL AUDITS: (Most recent)

Hand Hygiene Audit 100%

Environmental Audit 91.4%

Infection Control Audit 90%

Our Clinical Audit Programme is set and conducted via the Ramsay Clinical Audit Programme audit shown in Appendix 2.

2.2.2 Participation in clinical audit

During 1 April 2017 to 31st March 2018 West Midlands Hospital participated in 4 national

clinical audits.

The national clinical audits that West Midlands Hospital participated in, and for which

data collection was completed during 1 April 2017 to 31st March 2018, are listed below

alongside the number of cases submitted to each audit or enquiry as a percentage of the

number of registered cases required by the terms of that audit or enquiry.

Name of audit / Clinical Outcome Review Programme

% cases

submitted

National Joint Registry (NJR) 100%

Elective surgery (National PROMs Programme 100%

The reports of the national clinical audits from 1 April 2017 to 31st March 2018 were

reviewed by the Clinical Governance Committee and West Midlands Hospital intends to

take the following actions to improve the quality of healthcare provided.


Review of findings from 2015 / 16 NJR audit:

• 91.5% of eligible records were submitted

• 274 Matched records

• 33 Unmatched records (records in the provider extract with no corresponding

NJR record)

78.8% of the unmatched records had failed to be submitted to the NJR

12.1% were submitted with a different patient id

6.1% had the operation date incorrectly recorded

3.0% were procedures not included in the audit

• 10 Records on the NJR with no corresponding record in the provider extract

• Of those records which were not submitted to the NJR(26 records)

38.5% were primary knee procedures

61.5% were primary hip procedures

• 2 Consultant’s procedures accounted for 58% of the missing records

• The audit was carried out quickly & efficiently

The following actions have been recommended following the report and finding s above.

Findings. Action Required Individual responsible.

Date completed.

8.5% Eligible Records were missing

Ensure all records are submitted

Petra Phillips / Helen Lamb

Ensure no unmatched records.

Ensure robust system in place for matching data.


Records on NJR without corresponding record in provider extract.

Ensure Robust system in place for capturing data.

Petra Phillips / Helen Lamb.

2 consultants with 58% missing records.

Identify and Review with consultants missing records.


Share audit findings with Consultants / CGC /MAC

Email to all consultants.

Matron / CJ/ QIM May 2018 CGC

Complete 2016 /17 Data.

Submit audit. Petra Philips/ QIM May 2018

The 2016/17 NJR data report is awaited.


Local Audits

The reports of 107 local clinical audits from 1 April 2017 to 31st March 2018 were reviewed by the Clinical Governance Committee. It was noted by the CGC chair that where audit results fell below 90% an action plan was implemented and reviewed accordingly. An example of the Clinical Audit Schedule can be found in Appendix 2.

2.2.3 Participation in Research

There were no patients recruited during 2017/18 to participate in research approved by a

research ethics committee.

2.2.4 Goals agreed with our Commissioners using the CQUIN

(Commissioning for Quality and Innovation) Framework

A proportion of West Midlands Hospital income from 1 April 2017 to 31st March 2018

was conditional on achieving quality improvement and innovation goals agreed West

Midlands Hospital and any person or body they entered into a contract, agreement or

arrangement with for the provision of NHS services, through the Commissioning for

Quality and Innovation payment framework.

The Clinical Commissioning Group agreed the following CQUIN targets for 2017/18:

CQUIN 1 - Embedding a culture of learning.

This CQUIN enabled WMH to identify opportunities for integrated learning across the

organisation from any of the events to include serious incidents, complex complaints, and

near misses giving an opportunity to ensure learning is in place.

Embedding a culture of learning is an important part of both Ramsay Health Care and

West Midlands Hospital risk management strategy.

The CQUIN was successfully achieved and has helped to ensure that we as a hospital:

• Provide a safe environment for staff, patients and visitors by preventing harm and

learning from incidents that occur to improve the quality and safety of our services and

facilities.

• Foster a culture of reporting and recording incidents, near misses and harm


• Ensure that all staff are fully aware of the procedures regarding incident reporting

and their responsibilities within this area

• Ensure appropriate notification and escalation of incidents

• Ensure that any outcomes of investigations or any actions required to remedy

deficiencies, to prevent, so far as is reasonably practicable, a recurrence are

communicated and actioned correctly.

• Implements a consistent reporting framework for the review of incident trends at

local and national committees

• Meets the requirements set out in the Health and Social Care Act and Care

Quality Commission (CQC) regulations.

• Meets the requirements set out in the Health and Safety at Work etc. Act 1974

and the Reportable Disease and Dangerous Occurrence Regulations 1995 (RIDDOR).

CQUIN 2 Pre-operative tests in Line with NICE guidance

CQUIN 2 West Midlands Hospital was to evidence that appropriate pre-operative tests

are being carried out for all elective surgery in line with NICE Guidelines (April 2016).

This guideline covers routine preoperative tests for people aged over 16 who are having

elective surgery. It aims to reduce unnecessary testing by advising which tests to offer

people before minor, intermediate and major or complex surgery, taking into account

specific comorbidities (cardiovascular, renal and respiratory conditions and diabetes and

obesity).

The aim of this CQUIN is to ensure that all patients attending West Midlands Hospital

receive appropriate advice and support prior to an elective procedure taking place. To

review patient satisfaction as a result of information offered by the provider thus allowing

services to assess and improve the patient experience and ensure that the pre-operative

processes are robust and follow NICE guidelines.

This CQUIN has been successfully achieved and has allowed the pre assessment services to assess and improve the patient experience and ensure that the preoperative processes are robust and follow NICE guidelines introduced in April 2016. Since introducing this CQUIN there has been a reduction in the number of tests being carried out outside of NICE guidelines. The reason for this is Pre Assessment nurses are more aware of the NICE guidance and recommendations and check before referring patients for tests.

2.2.5 Statements from the Care Quality Commission (CQC)


West Midlands Hospital is required to register with the Care Quality Commission and its

current registration status on 31st March is registered without conditions.

The Care Quality Commission (CQC) attended West Midlands Hospital to undertake an

announced inspection on the 1st and 2nd December 2015. Staff, patients and clinical

departments were visited, along with a thorough inspection into all elements of our

hospital care. The final report was issued on 7th June 2016.

CQC ratings grid:

A copy of the full detailed report can be found at http://www.cqc.org.uk/location/1-128733177

A full action plan was implemented immediately, where robust actions and commitment to fulfil regulations were commenced. To Summarise:

http://www.cqc.org.uk/location/1-128733177

http://www.cqc.org.uk/location/1-128733177


Investigation Finding: Regulation 17 HCSA (RA) Regulations 2014 Good Governance – Regulation 17, 2 (b) The Provider did not have a robust governance process in place and oversight of risks for the safe use and handling of medicines.

What we did: Senior ward nurse/T&D Coordinator lead staff awareness and engagement process and plan which included, as examples – Information displays, flow chart re reportable incidents or errors and policy requirements, staff resource folder etc.

What we did: Existing SLA with local NHS Trust reviewed to increase Pharmacist input. This was to include audit/representation at CGC meetings/training as required/formal reviews of practice and audit outcomes/patient drug prescription reconciliation as examples.

What we did: Drugs and Therapeutics remains a standard agenda item on Clinical Hods/CGC agendas – ensure ALL local and corporate communications, incidents, shared learning and alerts are reviewed and documented

What we did: Requested an audit review from Ramsay healthcare UK to review compliance and identify any additional actions to be implemented

What we did: Drug calculations assessments remain part of recruitment process as a requirement to achieve employment and all existing staff will have 2 yearly reassessments

What we did: Compliance to local and corporate policies re SOPs e.g. theatre drug fridge temperature recording audited weekly and non-compliance identified to SMT until compliance improved and maintained


Investigation Finding: Regulation 17 HCSA (RA) Regulations 2014 Good Governance – Regulation 17, 2 (c) The Provider did not ensure that hospital staff had access to all necessary information, including maintaining an accurate, complete and contemporaneous record in respect of each patient and of decisions taken in relation to the care and treatment provided.

What we did: Communicate again to all non - compliant consultants of legal requirement for West Midlands Hospital to have access to contemporaneous set of notes on site

What we did: Agree process to be implemented with consultants and off site medical secretaries

What we did: Continue to ensure all new consultants are inducted with requirement to retain all notes on site in one complete patient record. Monitor via induction process and audit

What we did: Implement agreed processes with consultants and medical secretaries

What we did: Medical records audit quarterly to identify any lack of compliance to address and action where appropriate

During the time of writing this report, West Midlands Hospital were given notice for a planned inspection for 31st May 2018, and West Midlands Hospital is looking forward to sharing the improvements made since the last inspection. The final CQC report will not be ready in this reporting period.


2.2.6 Data Quality

Statement on relevance of Data Quality and your actions to improve your

Data Quality

The annual audit program reviews the quality of our data via clinical systems together with medical and paper records (Appendix 2). All audit results are discussed at the MAC, Clinical Governance Committee, and Health and Safety meeting and action plans in place reviewed.

West Midlands Hospital will be taking the following actions to improve data quality:

Continue to provide comprehensive reports for the MAC and CGC regarding clinical audit results.

Improve engagement with consultants regarding the importance of accurate patient data collection on written records. For example improving comprehensive completion of consent forms e.g. requests for additional tests.

Review and improve the PROMS data collection process to ensure all patients eligible to participate in the questionnaire are provided with a questionnaire.

NHS Number and General Medical Practice Code Validity

West Midlands Hospital submitted records during 2017/18 to the Secondary

Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are

included in the latest published data. The percentage of records in the published data

which included:

The patient’s valid NHS number:

99.98 % for admitted patient care;

99.96 % for out-patient care; and

N/A% for accident and emergency care (not undertaken at our hospital).

The General Medical Practice Code:

100% for admitted patient care;

99.99% 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 overall score for 2017/18

was 83% and was graded ‘green’ (satisfactory).

This information is publicly available on the DH Information Governance Toolkit website

at: https://www.igt.hscic.gov.uk

Clinical coding error rate

West Midlands Hospital was not subject to the Payment by Results clinical coding audit

during 2017/18 by the Audit Commission.

https://www.igt.hscic.gov.uk/


2.2.7 Stakeholders views on 2017/18 Quality Account

Comments from commissioners: Awaited


Part 3: Review of quality performance 2017/2018

Statements of quality delivery

Matron, Terri Burkett

Review of quality performance 1st April 2017 - 31st March 2018

Introduction

Statement from Vivienne Heckford

“This publication marks the eighth successive year since the first edition of Ramsay

Quality Accounts. Through each year, month on month, we analyse our performance on

many levels, we reflect on the valuable feedback we receive from our patients about the

outcomes of their treatment and also reflect on professional opinion received from our

doctors, our clinical staff, regulators and commissioners. We listen where concerns or

suggestions have been raised and, in this account, we have set out our track record as

well as our plan for more improvements in the coming year. This is a discipline we

vigorously support, always driving this cycle of continuous improvement in our hospitals

and addressing public concern about standards in healthcare, be these about our

commitments to providing compassionate patient care, assurance about patient privacy

and dignity, hospital safety and good outcomes of treatment. We believe in being open

and honest where outcomes and experience fail to meet patient expectation so we take

action, learn, improve and implement the change and deliver great care and optimum

experience for our patients.”

Vivienne Heckford

Director of Clinical Services

Ramsay Health Care UK

Ramsay Clinical Governance Framework 2018

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


National Guidance

Ramsay also complies with the recommendations contained in technology appraisals

issued by the National Institute for Health and Clinical Excellence (NICE) and Safety

Alerts as issued by the NHS Commissioning Board Special Health Authority.

Ramsay has systems in place for scrutinising all national clinical guidance and selecting

those that are applicable to our business and thereafter monitoring their implementation.

3.1 The Core Quality Account indicators

MORTALITY

West Midlands Hospital considers that this data is as described for the following reasons.

There was one patient death at West Midlands Hospital in this reporting period.

West Midlands Hospital did a full investigation into this case and learning can be found in section 3.3.2.

Prescribed Information Related NHS Outcomes Framework Domain

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to— (a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator.

1: Preventing People from dying prematurely 2: Enhancing quality of life for people with long-term conditions


West Midlands Hospital continues to implement the following actions to reduce this rate by;

Completion of Corporate audits, statutory notifications, incident investigation, root cause analysis of care episodes and continuous evaluation of care.

Robust mandatory training programme compliance

Information sharing at Clinical Governance level locally, corporately and with our commissioners. Governance is also shared at local Medical advisory committee and risk management meetings.

PROMS

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s patient reported outcome measures scores for— (i) groin hernia surgery, (ii) hip replacement surgery, and (iii) knee replacement surgery during the reporting period.

3: Helping people to recover from episodes of ill health or following injury

West Midlands Hospital considers that this data is as described for the following reasons:

Patients at the West Midlands Hospital have reported better than the national average for health gain for both primary hips and primary knee replacements.


Our response rate for groin hernia was too small to quantify outcome measure for the reporting period April 15 -March 16.

Patients at the West Midlands Hospital have reported better than the national average for health gain for groin hernia in data period April 16-March 17.

West Midlands Hospital has taken the following actions to maintain and improve this score by:

Engaging staff and raise importance awareness of PROMS to encourage an even greater participation rate.

Share progress/updated information with all departments at regular intervals to encourage this engagement.

READMISSIONS

West Midlands Hospital considers that this data is as described for the following reasons

Data in the reporting period 16/17 is much better than the England National Average, with fewer patients needing to be re-admitted following surgery at West Midlands Hospital.

West Midlands Hospital has taken the following actions to improve this score so the quality of its services can be consistently monitored;

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged— (i) 0 to 14; and (ii) 15 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.

3: Helping people to recover from episodes of ill health or following injury


Completion of clinical incident reports for all readmissions with incident investigation

and root cause analysis if required.

Information sharing through our local Medical Advisory Committee and the Clinical

Governance meetings held locally and corporately.

VENOUS THROMBOEMBOLISM (VTE)

(97.8% in colour graph)

West Midlands Hospital considers that this data is as described for the following

reasons;

We have a robust patient assessment process coupled with the co-operation of all of our consultants this has ensured we always aim to reach full compliance for venous thromboembolism assessment thereby minimising the risk for all patients. The VTE assessment documentation is now issued at pre-operative assessment

0.8

0.82

0.84

0.86

0.88

0.9

0.92

0.94

0.96

0.98

1

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

West MidlandsHospital

Excellent

Good

Fail

Actual

Target

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

5: Treating and caring for people in a safe environment and protecting them from avoidable harm


where the assessment is instigated by the nurse it is then completed by the admitting consultant.

West Midlands Hospital has taken the following actions to improve and maintain this percentage and so the quality of its services.

VTE assessment forms part of the Ramsay patient pathway and these are completed on admission for all patients

The completed discharge medical record check for all patients forms an additional system check for the documented VTE assessment this is then marked accordingly within the patient’s cosmic record.

Monthly checks of corporate report for VTE assessments are completed

CLOSTRIDIUM DIFFICILE RATES


reasons

West Midlands Hospital shows lower than average rates of clostridium difficile infection. It should be noted that West Midlands Hospital has again achieved a zero rate of clostridium difficile infections.

An annual strategy for Infection Prevention and Control (IPC) is developed at a corporate level by the Group.

IPC and policies are revised and redeployed every two years. Infection and Prevention programmes are designed to bring about improvements in performance and practice.

A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and best clinical practice.

West Midlands Hospital employs a Specialist Infection Control Nurse and there are Infection Control link nurses in all clinical areas ensuring that IP& C management remains a high priority throughout the hospital.

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.



West Midlands Hospital has taken the following actions to improve this score so the quality of its services can be consistently monitored and its objective will be to maintain a zero rate of clostridium difficile infections in the year;

Maintain high standards of Infection Prevention and Control practice to minimise the risk of occurrence of clostridium difficile infections.

Implement the correct treatment and nursing intervention for any confirmed or suspected clostridium difficile infections

Report any incidence of clostridium difficile infections to the appropriate Public Health bodies, responsible microbiologist, consultants and clinical commissioning groups.

Follow national and corporate guidance on Infection Prevention and Control standards, audits and processes.

SERIOUS UNTOWARD INCIDENTS

The West Midlands Hospital reports any type of incident on an internal reporting system.

Any Serious Untoward incidents are reported to external bodies accordingly.

West Midlands Hospital considers that this data is as described for the following reasons

Severity 1 described as ‘severe/Death’.

Acute Non-Specialist Data From NRLS, England Average based on these sites only

The Riskman system reports incidents directly to the Corporate Risk Management Team allowing the identification of trends at the West Midlands

West Midlands Hospital has taken the following actions to maintain the quality of its services.

Maintaining a robust staff induction and mandatory training programme

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death



The senior management team ensure that incidents are investigated and when lessons are learned from these events they are shared with staff across the hospital so that we can prevent the same type of incidents happening again.

All incidents are reviewed by the General Manager and Matron and an investigation process, Root Cause Analysis and action plan implemented where appropriate.

Promoting the use of comprehensive risk assessment tools that are available to identify and minimise risk

The Centralised Alert System (CAS) disseminates all alerts for NPSA/ MDE and FSN to all departments with required actions feedback.

A falls assessment tool has been implemented successfully throughout the hospital and is used whenever any risk of falls is identified.

All patients on the medical ward complete a falls risk assessment on admission

FRIENDS AND FAMILY TEST

The NHS-wide ‘Friends and Family’ test to improve patient care and identify the best

performing hospitals in England was announced in 2012 by the Prime Minister. Since this

date the Friends and Family survey has been expanded year on year at the West

Midlands Hospital and now incorporates all of our departments.


reasons

• In the reporting period, West Midlands Hospital achieved higher than the national average for patient satisfaction score.

• All patients at the West Midlands Hospital are now routinely invited to take part in this anonymous survey asking simply whether they would recommend our

Friends and Family Test – Patient. The data made available by National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2)

4: Ensuring that people have a positive experience of care This indicator is not a statutory requirement.


hospital to their family and friends. This is reflected in our increasing response rates and current high score of 99.4% would recommend us to their friends and family.

West Midlands Hospital has taken the following actions to improve and maintain the quality of its services by:

Use the Friends and family survey feedback to continuously monitor patient feedback in all departments

Disseminating individual department feedback from the Family and Friends survey on a weekly basis; this is via email as a weekly staff update.

Acting on patient feedback and complaints to improve quality in areas where any issues may have been identified

Using corporately generated Friends and Family results to analyse and act upon any trends, individual comments and suggestions for improvement.

3.2 Patient safety

We are a progressive hospital and focussed on stretching our performance every year

and in all performance aspects, 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.

3.2.1 Infection prevention and control

West Midlands Hospital has a very low rate of hospital acquired infection and has

had no reported MRSA Bacteraemia in the past 3 years.

We comply with mandatory reporting of all Alert organisms including MSSA/MRSA

Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents

year on year.

Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic

joint surgery and these are also monitored.


Infection Prevention and Control management is very active within our hospital. An

annual strategy is developed by a Corporate level Infection Prevention and Control (IPC)

Committee and group policy is revised and re-deployed every two years. Our IPC

programmes are designed to bring about improvements in performance and in practice

year on year.

A network of specialist nurses and infection control link nurses operate across the

Ramsay organisation to support good networking and clinical practice.

Programmes and activities within our hospital include:

The following local infection prevention and control audits were carried out;

Table 1: Local Infection prevention and control audits

As seen in Table 1 above, a total of 20 infection prevention and control audits were carried out. Any audit that fell below 90% a robust action plan was put in place and re-audited after an appropriate time scale.

Audit: Score:

IPC infection control (Oct 17) 90%

IPC cleaning schedules (Sep 17) 89%

IPC cleaning schedules (Oct 17) 90%

IPC cleaning schedules (Dec 17) 98%

IPC cleaning schedules (March 18) 93%

IPC infection control (March 18) 93%

IPC Environmental (Oct 17) 90%

IPC Environmental (March 18) 93%

IPC Hand Hygiene (April 17 -March 18, x 12 audits)

100%


The Bar chart above shows an increase of infections since 2016/17. This is partly due to

a change in reporting process at West Midlands Hospital, where any suspected infection

was reported, and not just confirmed infections. The infection rate is still very low in

proportion to the number of admissions, with less than 0.3% infection rate.

3.2.2 Cleanliness and hospital hygiene

Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at West Midlands Hospital, providing us with a patient’s eye view of the buildings, facilities and food we offer, giving us a clear picture of how the people who use our hospital see it and how it can be improved. The main purpose of a PLACE assessment is to get the patient view.

Domains Score 2016 Score 2017

Cleanliness 98% 93%

Food 95.9% 85.3%

Organisational Food 96.32% 89.54%

Ward Food 95.58% 80.55%

Privacy and Dignity 70.97% 60.80%

Condition and Maintenance 92.19% 82.98%

Dementia 49.16% 39.83%

Disability 60.33% 54.95%

0

0.05

0.1

0.15

0.2

0.25

0.3

2015/16 2016/17 2017/18

Infe

ctio

n R

ates

(p

erce

nta

ge o

f A

dm

issi

osn

s)

West Midlands Hospital

Infection Rates


PLACE Action plan

Food

It was agreed that Hygiene hand wipes would be introduced as an option for patients to

use prior to eating. These are to be placed on each tray.

West Midlands Hospital discussed with corporate the availability of menus in other

languages, large print and Braille options. Large print and Braille available and being

used.

Privacy and dignity

Reception areas- it was noted that not enough chairs were available in the waiting area,

and that there was not enough space for those patients standing (despite empty chairs)

for private conversations. As a result, extra chairs added for physio patient waiting area

outside the physiotherapy department.

Condition and Maintenance.

The West Midlands hospital has undergone an extensive refurbishment programme, with

many substantial upgrades to patient rooms, corridors, treatment rooms and storage

areas.

Cleanliness

Monthly cleaning audits have been reviewed and improved, the Head of House Keeping

now also does monthly cleaning audits.


3.2.3 Safety in the workplace

Safety hazards in hospitals are diverse ranging from the risk of slips, trips or falls to

incidents involving sharps and needles. As a result, ensuring our staff have high

awareness of safety has been a foundation for our overall risk management programme

and this awareness then naturally extends to safeguarding patient safety. Our record in

workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the

results of safety training and local safety initiatives.

Effective and ongoing communication of key safety messages is important in healthcare.

Multiple updates relating to drugs and equipment are received every month and these

are sent in a timely way via an electronic system called the Ramsay Central Alert System

(CAS). Safety alerts, medicine / device recalls and new and revised policies are

cascaded in this way to our General Manager which ensures we keep up to date with all

safety issues.

3.3 Clinical effectiveness

West Midlands Hospital has a Clinical Governance team and committee that meet regularly

through the year to monitor quality and effectiveness of care. Clinical incidents, patient

and staff feedback are systematically reviewed to determine any trend that requires

further analysis or investigation. More importantly, recommendations for action and

improvement are presented to hospital management and medical advisory committees to

ensure results are visible and tied into actions required by the organisation as a whole.

3.3.1 Return to theatre

Ramsay is treating significantly higher numbers of patients every year as our services

grow. The majority of our patients undergo planned surgical procedures and so

monitoring numbers of patients that require a return to theatre for supplementary

treatment is an important measure. Every surgical intervention carries a risk of

complication so some incidence of returns to theatre is normal. The value of the

measurement is to detect trends that emerge in relation to a specific operation or specific

surgical team. Ramsay’s rate of return is very low and is consistent with our track record

of successful clinical outcomes.


The Bar graph above shows a reduction in return to theatre rate for two consecutive

years.

3.3.2 Learning from Deaths

There was one death reported in the period, this has been reviewed as a single investigation. The death occurred within the 30 day of patient procedure, from pre-existing condition. Following this investigation, there were no learnings to take that would have prevented this death occurring.

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

0.2

2015/16 2016/17 2017/18

Ret

rnn

to

Th

eatr

e

(Per

cen

tage

of

Ad

mis

sio

sns)


Return to Theatre Score


3.3.3 Priority Clinical Standards for Seven Day Hospital Services

Priority Clinical Standard: 1 Patients, and where appropriate families and carers, must be

actively involved in shared decision making and supported by clear information from

health and social care professionals to make fully informed choices about investigations,

treatment and on-going care that reflect what is important to them. This should happen

consistently, seven days a week.

At West Midlands Hospital our Consultants are available 7 days a week to provide

support to patients and families under their care. All patients are reviewed daily ensuring

they are actively involved in shared decision making, supported by clear information,

helping patients make fully informed choices about investigations, treatment and on-

going care that reflects what is important to the patient.

Priority Clinical Standard: 2 Time to first consultant review - All emergency admissions

must be seen and have a thorough clinical assessment by a suitable Consultant as soon

as possible but at the latest within 14 hours from the time of arrival at hospital.

At West Midlands Hospital we predominantly carry out elective surgery, where a patient

has to be re-admitted acutely following a procedure, our Resident Medical Officer (RMO)

and the Consultant will review the patients. Both the RMO and Consultant carry out a

thorough clinical assessment and a plan of care is made by the Consultant.

Priority Clinical Standard 3: Standard: All emergency inpatients must be assessed for

complex or on-going needs within 14 hours by a multi-professional team, overseen by a

competent decision-maker, unless deemed unnecessary by the responsible Consultant.

An integrated management plan with estimated discharge date, physiological and

functional criteria for discharge must be in place along with completed medicines

reconciliation within 24 hours.

The multi-professional team at West Midlands Hospital consists of the nursing team,

Consultant Surgeon, anaesthetist, physiotherapist, radiographers and the RMO. For

every patient the named Consultant is available within 30 minutes of the hospital for

emergency needs. The anaesthetist, physiotherapists and Radiographers are available 7

days a week and out of ours there is an on call service to provide the support to the

patient in an emergency.


Priority Clinical Standard 4: Handovers must be led by a competent senior decision

maker and take place at a designated time and place, with multi-professional

participation from the relevant in-coming and out-going shifts. Handover processes,

including communication and documentation, must be reflected in hospital policy and

standardised across seven days of the week.

All care provided to patients at The West Midlands Hospital is led by a named

Consultant; planned care is communicated to the nursing staff and RMO through both

verbal and written instruction. Patients are seen and reviewed by Consultants 7 days a

week. The nursing team carry out a comprehensive handover from shift to shift which is

led by a senior nurse.

Priority Clinical Standard: 5 Hospital inpatients must have scheduled seven-day access

to diagnostic services, typically ultrasound (USS), Computerised Tomography (CT),

Magnetic Resonance Imaging (MRI), echocardiography, endoscopy, and microbiology.

Consultant-directed diagnostic tests and completed reporting will be available seven

days a week:

• Within 1 hour for critical patients.

• Within 12 hours for urgent patients.

• Within 24 hours for non-urgent patients.

At The West Midlands Hospital all in-patients can access diagnostic services (USS, CT,

MRI, microbiology, pathology) seven days a week. Access to the services can be

provided to meet the needs of the patient, within 1 hour for critical patients, 12 hours for

urgent patients, and 24 hours for non-urgent patients. All requests are made by the RMO

or Consultant and always reviewed / reported by the Consultant. Where we cannot

access on site services we would access offsite via our local NHS trust.

Priority Clinical Standard 6: Hospital inpatients must have timely 24 hour access, seven

days a week, to key Consultant-directed interventions that meet the relevant specialty

guidelines, either on-site or through formally agreed networked arrangements with clear

written protocols.


At West Midlands Hospital all our In-patients have timely 24 hour access, seven days a

week to key consultant directed interventions that meet the relevant speciality guidelines;

if this cannot be provided on site we have formally agreed arrangements with the local

NHS Trusts and have clear written protocols.

Example:

Critical care / HDU – Russell’s Hall Hospital

Emergency general surgery can be provided onsite as we a have on call team.

3.4 Patient Experience

All feedback from patients regarding their experiences with Ramsay Health Care are welcomed and help to inform the service development in various ways dependent on the type of experience (both positive and negative) and actions 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 shared with relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.

Patient experiences are fed back via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy.

Feedback regarding the patient’s experience is encouraged in various ways via:

Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48hrs of a patient making a comment on their web survey Yearly CQC patient surveys Friends and Family questions asked on patient discharge ‘We value your opinion’ leaflet Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers

whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/emails Patient focus groups


PROMs surveys Care pathways – patient are encouraged to read and participate in their plan of care

3.4.1 Patient Satisfaction Surveys

Our patient satisfaction surveys are managed by a third party company called ‘Qa Research’. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient’s views.

Every patient is asked their consent to receive an electronic survey or phone call following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services. Any text comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital Manager within 48hrs of receiving them so that a response can be made to the patient as soon as possible.

As can be seen in the above graph our Patient Satisfaction rate has increased over the last year. We will continue to collate patient feedback and review accordingly to achieve and maintain a high satisfaction score.

3.5 West Midlands Hospital Case Study

The West Midlands Hospital did not have a case study to review this year.

90.3 96.0

0

20

40

60

80

100

120

2016/17 2017/18

Sati

sfac

tio

n S

core

s


Satisfaction Scores NHS/Private Patients


Appendix 1

Services covered by this Quality Account

The Hospital provides NHS and private inpatient and outpatient facilities for:-

Breast care

Dermatology

Ear, Nose and Throat (ENT)

Gastroenterology

General Surgery

Gynaecology

Ophthalmology

Oral maxillofacial

Orthopaedics

Spinal

Pain Management

Physiotherapy

Urology

Vascular

Diagnostics


Appendix 2 – Clinical Audit Programme 2017/18. Findings from the baseline audits will determine the

hospital local audit programme to be developed for the remainder of the year.

Local audit programme to be added in below national programme



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:

01384 560123

http://www.westmidlandshospital.co.uk/

http://www.westmidlandshospital.co.uk/

Documents

Quality Account 2017/18€¦ · Quality Accounts 2017/18 Page 5 of 48 Introduction to our Quality Account This Quality Account is West Midlands Hospital’s annual report to the public