Bodmin NHS Treatment Centre. Quality Account 2015/16

Transcription

1 Bodmin NHS Treatment Centre Quality Account 2015/16

2 Contents Introduction Page Welcome to Ramsay Health Care UK Introduction to our Quality Account PART 1 STATEMENT ON QUALITY 1.1 Statement from the General Manager 1.2 Hospital accountability statement PART Priorities for Improvement Review of clinical priorities 2015/16 (looking back) Clinical Priorities for 2016/17 (looking forward) 2.2 Mandatory statements relating to the quality of NHS services provided Review of Services Participation in Clinical Audit Participation in Research Goals agreed with Commissioners Statement from the Care Quality Commission Statement on Data Quality Stakeholders views on 2015/16 Quality Accounts PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 The Core Quality Account indicators 3.2 Patient Safety 3.3 Clinical Effectiveness 3.4 Patient Experience Appendix 1 Services Covered by this Quality Account Appendix 2 Clinical Audits

3 Welcome to Ramsay Health Care UK Bodmin NHS Treatment Centre is part of the Ramsay Health Care Group The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals. We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Group. I Statement from Mark Page CEO 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. 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 improvements that will keep it at the forefront of health care delivery. I am very proud of Ramsay Health Care s reputation as a global leader in the delivery of safe and quality care. It gives us pleasure to share our results with you. Mark Page Chief Executive officer Ramsay Health Care UK Page 3 of 37

4 Introduction to our Quality Account This Quality Account is Bodmin NHS Treatment Centre s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on. Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this didn t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share. Page 4 of 37

5 Part Statement on Quality from the General Manager Chris Sealey, General Manager Bodmin NHS Treatment Centre Welcome to Bodmin Treatment Centres Quality Account. This report outlines the Hospital's approach to quality improvement, progress made in and plans for the forthcoming year. Bodmin Treatment Centre has five key values which underpin everything we do as an organisation: Put the patient first Work as one team Respect each other Strive for continual improvement Respect environmental sustainability The aim of our Quality Account is to provide information to our patients and commissioners to assure them we are committed to making progressive achievements. For example, we participate in the Friends and Family survey, and have made progress this year in participation, and retained our very high recommendation rates. Our emphasis is on ensuring patients receive safe and effective care, that they feel valued and respected in decisions about their care and are fully informed about their treatment at each step of the pathway. The experience that patients have in our hospital is of the utmost importance and we are committed to continuing to develop our organisational culture which puts the patient at the centre of everything we do. As well as being treated quickly and safely, our patients receive a personalised service, enhanced by good communication and a commitment to ensuring their privacy and dignity are respected at all times. Page 5 of 37

6 High quality patient care is at the centre of what we do and how we operate our hospital. To do this we rely on excellent medical and clinical leadership plus an overall continuing commitment to drive year on year improvement in clinical outcomes. We especially value patient s feedback about their stay, treatment and clinical outcome. In the last year we have continued to complete regular patient surveys and received excellent feedback. We have continued to participate in the NHS Friends and Family Survey and we have been delighted with the results and comments received from patients. The Patient Reported Outcome Measures score for our Hernia patients is amongst the very best in the country. 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 Chris Sealey General Manager Bodmin NHS Treatment Centre Ramsay Health Care UK This report has been reviewed and approved by: Mr Charles Lansley MAC Chair Dr Marek Woyton Clinical Governance Committee Chair Mark Bounds Regional Director, Ramsay Health Care UK Kernow Clinical Commissioning Group Page 6 of 37

7 Welcome to Bodmin NHS Treatment Centre Bodmin NHS Treatment Centre is a purpose built day unit built in 2005 to work in partnership with the NHS. It is equipped with 2 Theatres and a designated Endoscopy suite. The Treatment Centre provides NHS services throughout Cornwall and Devon. We provide fast, convenient, effective and high quality treatment for patients over the age of 18. Bodmin NHS Treatment Centre s services include the specialities; dermatology, ear, nose & throat (ENT), endoscopy, general surgery, gynaecological, ophthalmic, maxilla/facial/oral, urology and orthopaedics. We have 2 outreach clinics for general surgery at Penzance and Bude. We are committed to providing our healthcare resources nearer to the patient s homes whenever it is safe to do so. Total number of patient admissions in the past year was almost 5000 We employ 39 contracted staff; 3 Employed Doctors, 11 Trained Nurses. 5 Healthcare assistants, 4 Housekeepers, 1 Stores persons and 11 Admin staff. We also share an Accountant, GP Liaison and Engineer with the Duchy hospital. We have 25 Consultants with Practising Privileges, 6 with Medical Service Agreements including 4 Ophthalmic Surgeons. We receive our referrals from both the Kernow Referral Management Service and the Devon Referral Support Service. Jordan Wood has recently been appointed as our new GP Liaison Manager. She will endeavour to keep the practices up to date with all the services available at Bodmin, answer any queries that may arise and build good relations between all parties. We work closely with the Royal Cornwall Hospital Treliske who provide us with blood transfusion, histology and access to critical care services. We have a good working relationship with our GPs and a local GP sits on our Medical Advisory Committee. We participate in and support numerous local and national charity events on a regular basis. Our nominated charity is the Cornwall air ambulance service. We advertise our services in the local press and local radio. We have just celebrated our 10 th Anniversary, and over the last decade we have performed over, 12,000 Cataract procedures, 15,000 endoscopies, 2,000 hernias, 3,500 max/fax procedures, 3,000 dermatology procedures, 4,700 gynaecological procedures, 1,000 orthopaedic procedures and 400 ENT procedures. Page 7 of 37

8 Part Quality priorities for 2015/2016 Plan for 2015/16 On an annual cycle Bodmin NHS Treatment Centre develops an operational plan to set objectives for the year ahead. We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all 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. Page 8 of 37

9 Priorities for improvement A review of clinical priorities 2015/16 Patient safety Surgical safety checklist compliance to the checklist is an ongoing quality initiative at Bodmin NHS Treatment Centre. Compliance to the surgical safety checklist will continue to be audited and the results reviewed at theatre departmental meetings, Clinical Governance and Risk Management meetings. 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 reviewed at the Clinical Governance Committee. The results for the past 12 months are all above the target 90%. Never events - preventing the occurrence of any serious, largely preventable patient safety incidents that should not occur will remain a clinical priority for 2015/16. Training Bodmin NHS Treatment Centre will continue to ensure that patients are cared for by safe and competent staff. In addition to our robust competency based training programme we have also introduced PREVENT Awareness Training. This training commenced in 2014, for all staff and has been added to our in house training program. Prevent self-assessment tool completed. Information Security in 2011 Bodmin NHS Treatment Centre achieved the information security accreditation IS The BSI Auditors carried out a re-certification audit of Bodmin Treatment Centre in November 14 and once again achieved the accreditation with outstanding results. The process of raising awareness of the importance of data protection and information security has been very successful and fully embraced by the staff at Bodmin NHS Treatment Centre Pathways in we reviewed our clinical pathways with the aim of reducing patient visits to our unit. We have reduced all follow up appointments to a minimum and increased the availability of See and Treat cataract appointments, one stop diagnostic urology appointments and direct access endoscopy. We have also expanded our outreach clinics to do initial consultations, pre assessment and follow up checks in Page 9 of 37

10 areas such as Penzance, and Bude and are looking to set up a cardiology outreach clinic in Launceston Clinical Priorities for 2016/17 For 2016/17 Bodmin Treatment Centre will strive to continue delivering a safe, high quality experience for all patients. In particular we will focus on: Patient Experience We will continue to work hard to ensure that all those who use our services have a positive experience. This year we will increase our focus to those attending as outpatients. We will monitor this through ratings in our patient survey and the national Friends and Family feedback which is high on our agenda. Clinical Effectiveness We will continue to look for pathway improvements to minimise the patient s visits to secondary care. Improve access for patients with outreach clinics and reduce wait times with more direct access and one stop appointments. In November 15 we commenced the pilot to transfer cataract patients for followup in the local community with optometrists. Combined with our already popular see and treat cataract service this will reduce the patient pathway to just one visit to secondary care. Duty of Candour, we are committed to being open and honest with our patients when a mistake has been made. Dealing with complaints, effectively, openly and honestly. Learning lessons from mistakes and acting on them. The culture should be openness and transparent. Page 10 of 37

11 Patient Safety We will continue our focus on surgical safety through use of the WHO checklist and other safe surgery processes We will continue to maintain our levels of VTE assessment compliance. We have recently implemented a system for the electronic transfer of discharge information to GPs so that the GPs receive electronically typed letters regarding their patient s treatment in a timely fashion. Going forward we intend to develop the functionality with our PAS to send this information directly to the GP s patient record. With the implementation of Ramsay s new Electronic Patient Information system in May 16 all patient information will be on recorded in an Electronic Patient Record. We will have electronic pathways for all patients and aim to be paper free by the end of Progress against all of these priorities will be monitored by the Senior Management Team and reported to our local Clinical Governance Committee. Those that are targets agreed with KCCG will also be reported in our monthly quality report to them. Clinical Effectiveness Ambulatory Day Care better outcomes and improving patient experience. Ambulatory day care is the admission of selected patients to hospital for a planned procedure, returning home the same day. Over recent years, partly due to medical advances, the number of day surgery patients has increased compared to those patients requiring inpatient care. Bodmin NHS Treatment Centre is a purpose built day case facility which has adopted efficient patient pathways with an average length of stay of 2.28 hours. Best practice has shown that by caring for short stay patients in a day care facility, as opposed to a traditional ward, patient care will improve as the waiting time and recovery period are reduced. Pre assessment Bodmin NHS Treatment Centre is a day case facility and we screen all patients prior to admission to identify the level of care they will require during their stay. Some are deemed too complex for treatment at this site and are referred to a more appropriate facility to meet their needs. Others are admitted with their level of care already defined and the necessary skilled staff, equipment and facilities available for them. Pre assessing patients at the start of their pathway is performed by highly skilled staff and conducted by either telephone assessment or a face to face examination. Page 11 of 37

12 Correctly assessing our patient s needs is an ongoing quality initiative for Bodmin NHS Treatment Centre. We always try to minimise patient visits to secondary care by doing their pre assessment checks at the time of consultation. National benchmarking - VTE risk assessment compliance benchmarking through the national stats website. See Bodmins actual compliance in the diagram below. chttp:// DH % 98% 96% 94% 92% 90% 88% 86% 84% 82% 80% Bodmin NHS Treatment Centre Excellent Good Fail Actual Target PROMS results benchmarking through national PROMS website Patient experience Patient reported outcome studies (PROMS) we participate in the national PROMS data collection for Hernia surgery. In 2015 we had one of the best outcomes scores in the whole country and we are proud of this achievement and hope to continue our excellent outcomes. Page 12 of 37

13 Satisfaction Scores Friends and Family Survey Bodmin also participates in this survey for outpatients and daycases patients. Our latest results show that 100% of our patients that responded, would definitely recommend Bodmin Treatment Centre to their friends and family. Patient satisfaction survey Bodmin NHS Treatment Centre s patient survey is consistently over 95%. If we fall short of any patients expectations and receive any poor results an action plan is completed and discussed at our Customer Focus Group to enable an improvement in the patient experience Satisfaction Scores NHS/Private Patients / /16 Bodmin NHS Treatment Centre PLACE Assessments Bodmin Treatment Centre has received excellent results from this patient led assessment of the hospital. Last one was May This years result is due in June 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. Page 13 of 37

14 2.2.1 Review of Services During 2015/16 Bodmin NHS Treatment Centre provided and/or subcontracted 10 NHS services. Bodmin NHS treatment Centre has reviewed all the data available to them on the quality of care in 10 of these NHS services. 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 2015/16, the indicators on the scorecard which affect patient safety and quality were: Human Resources Staff Cost 29% of Revenue HCA Hours as 40% of Total Nursing Staff Turnover 4.7% Sickness 5.06% Lost Time 21.% Appraisal 70 % Mandatory Training 86% Staff Satisfaction Score 76.5 % up from 67% in 2013 Number of Significant Staff Injuries - 0 Page 14 of 37

15 Patient Formal Complaints per 1000 HPD's 0.1% Patient Satisfaction Score 96.8% Significant Clinical Events per 1000 Admissions - 0 Readmission per 1000 Admissions no readmits back to Bodmin and very low numbers of patients sought treatment/advice at the local Trust following a procedure at Bodmin. Quality Workplace Health & Safety Score 95% Infection Control Audit Score above 95% Participation in clinical audit. Bodmin Treatment Centre does not participate in any of the National Clinical audits as they are not applicable to the services provided. Local Audits The reports of all local audits which include; Anaesthetics, Medical records, Consent, Discharge, Care Pathways & Variance tracking, Medicines Management, Controlled drugs, Environmental, VTE, Colposcopy, JAG & GRS and 9 infection prevention & control audits from 1st April 2015 to 31 st March 2016 were reviewed by the Clinical Governance Committee and hospital s MAC. All audit results showed an excellent degree of compliance and our main priority for 2016/17 will be ensuring standards of documentation are met with regard to discharge of patients. This is in line with the requirements of the National Standard Contract for NHS services. The clinical audit schedule can be found in Appendix Participation in Research Page 15 of 37

16 There were no patients recruited during 2015/16 to participate in research approved by a research ethics committee Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Bodmin NHS Treatment Centre s income in from 1 April 2015 to 31 st March 2016 was conditional on achieving quality improvement and innovation goals agreed Bodmin NHS Treatment Centre 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. Last year we achieved all our CQUINS We have agreed new targets for 2016/17 CQUIN Scheme 2016/17 Percentage Indicator weighting Introduction of staff health and wellbeing initiatives. 0.50% 100% Hand Hygiene- hand washing 1.00% 50% Hand Hygiene Availability of hand wash gels 1.00% 50% Statements from the Care Quality Commission (CQC) Bodmin NHS Treatment Centre is required to register with the Care Quality Commission and its current registration status on 31 st March 2016 is registered without conditions/registered with conditions. The Care Quality Commission has not taken enforcement action against Bodmin NHS Treatment Centre during 2015/2016. Bodmin NHS Treatment Centre has not participated in any special reviews or investigations by the CQC during the reporting period. Page 16 of 37

17 2.2.6 Data Quality Statement on relevance of Data Quality and your actions to improve your Data Quality We regularly use statistical data to monitor clinical services- we are constantly striving to improve this data by regular quality control initiatives. Data contained in medical records are audited on a monthly basis and actions taken to improve quality as appropriate. The hospital has a data quality super user who manages the SUS pathway processes and continually reviews administration functions to ensure data quality. NHS Number and General Medical Practice Code Validity Bodmin NHS Treatment Centre submitted records during 2014/15 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included: The patient s valid NHS number: 99.97% for admitted patient care 100% for outpatient care 0% for accident and emergency care (not undertaken at our hospital) The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; and 0% for accident and emergency care (not undertaken at our hospital) Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2015/16 was 85% and was graded green (satisfactory). Page 17 of 37

18 This information is publicly available on the DH Information Governance Toolkit website at: Clinical coding error rate Bodmin NHS Treatment centre was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission. Internal audit carried out in May 2015 showed primary diagnosis 98% and secondary diagnosis 96.1%. Page 18 of 37

19 2.2.7 Stakeholders views on 2015/16 Quality Account Statement from Kernow Clinical Commissioning Group for Bodmin Treatment Centre Quality Account 2015/16 NHS Kernow Clinical Commissioning Group (NHSK CCG) is the co-ordinating commissioner for Ramsay Bodmin Treatment Centre (BTC) and welcomes the opportunity to comment on their Quality Account for 2015/16. We believe Ramsay BTC have produced a balanced Quality Account which is easy to read and clearly laid out, and trust it will provide a useful tool to help the general public understand how their local health services are performing. There are routine processes in place with Ramsay BTC to agree, monitor and review the quality of services, covering the key quality domains of safety, effectiveness and experience of care. We have reviewed the information contained within this Quality Account and can confirm that it represents a fair reflection of the achievements of Ramsay BTC during 2015/16. Last year Ramsay BTC set out its goals for improving clinical priorities for the coming year and we commend the progress made. We are pleased to see the continued high patient satisfaction scores and particularly praise the hard work by staff members which resulted in significantly improved response rates to the Friends and Family test. Ramsay BTC has shown commitment to maintaining robust governance and reporting structures, including a strong focus on training and continued use of the WHO surgical safety checklist and venous-thromboembolism (VTE) assessments. Ramsay BTC routinely participate in the national Patient reported outcome studies (PROMS) and in 2015 they reported some of the highest scores in the country for hernia surgery. We are pleased to note that the priorities chosen for 2016/17 are evidence based and have a continued focus on patient safety and improving the patient pathway. Ramsay BTC has worked constructively with commissioners and other partners to respond to local commissioning needs and improve care pathways. Last year they helped develop a pilot scheme to provide follow up care closer to home, by transferring cataract patients due a routine follow-up to local optometrists. The scheme has now been fully launched and will be routine practice for 2016/17, helping to reduce the patient pathway for many patients to just a single visit to secondary care. We also commend the continued efforts to implement a new electronic patient record system that will improve patient safety and will ultimately enable information to be shared directly with the GP s patient record. We have been working collaboratively with Ramsay BTC to support their continuous quality improvement. They achieved all the Commissioning for Quality and Innovation (CQUIN) schemes set during 2015/16 and have worked with us to develop schemes for 2016/17 including improving staff health and wellbeing, and focusing on hand hygiene. We will continue to work closely with Ramsay BTC in 2016/17 to achieve ever more efficient pathways delivering high quality services to patients. Page 19 of 37

20 Part 3: Review of quality performance 2015/2016 Statements of quality delivery Jacqueline Preston - Matron Review of quality performance 1st April st March 2016 Introduction This publication marks the seventh 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 2016 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 Page 20 of 37

21 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 Page 21 of 37

22 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. Page 22 of 37

23 3.1 The Core Quality Account indicators Mortality Mortality: Period Best Worst Average Period Bodmin Oct 13-Sep 14 RKE RPA 1.20 Eng /14 NVC24 0 OCT 14- Sep 15 RKE RVW 1.18 Eng /15 NVC24 0 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 hospitallevel 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 Bodmin NHS Treatment Centre does not have any palliative care facilities

24 PROMS PROMS: Period Best Worst Average Period Bodmin Hernia Apr14-Mar15 RD R1H Eng Apr14 - Mar15 NVC Apr15 Sep15 RJL RR Eng Apr15 - Sep16 NVC24 * PROMS: Period Best Worst Average Period Bodmin Veins Apr14-Mar15 R1K 5.59 RTE Eng Apr14 - Mar15 NVC24 Apr15 Sep15 RK RM Eng Apr15 - Sep15 NVC24 PROMS: Period Best Worst Average Period Bodmin Hips Apr 14-Mar15 NTE RQX Eng Apr14 - Mar15 NVC24 Apr15 Sep15 NVC RJL Eng Apr15 - Sep15 NVC24 PROMS: Period Best Worst Average Period Bodmin Knees Apr 14-Mar15 NT RE Eng Apr13 - Mar14 NVC24 Apr15 Sep14 RVV RK Eng Apr15 - Sep15 NVC24 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) varicose vein surgery, (iii) hip replacement surgery, and (iv) knee replacement surgery, during the reporting period. 3: Helping people to recover from episodes of ill health or following injury Bodmin NHS Treatment Centre considers that this data is as described for the following reasons: Bodmin only undertakes the Hernia proms. Quality Accounts 2013/14 Page 24 of 37

25 Readmissions Readmissions: Period Best Worst Average Period Bodmin Multiple 0.0 5P Eng /11 NVC Multiple 0.0 5NL Eng /12 NVC24 0 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 Bodmin NHS Treatment Centre considers that this data is as described for the following reasons. There have been no readmissions in the last year. Personal needs Responsiveness Period Best Worst Average Period Bodmin to personal RPC 88.2 RJ Eng /13 NVC needs RPY 87.0 RJ Eng /14 NVC 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 responsiveness to the personal needs of its patients during the reporting period. 4: Ensuring that people have a positive experience of care Bodmin NHS Treatment Centre data is taken from the Ramsay Patient Survey and not the CQC in patient survey as we do not have in patients. Quality Accounts 2013/14 Page 25 of 37

26 VTE VTE Assessment: Period Best Worst Average Period Bodmin 15/16 Q2 Several 100% RWA 75.0% Eng 95.9% 15/16 Q2 NVC % 15/16 Q3 Several 100% RWW 61.5% Eng 95.6% 15/16 Q3 NVC % 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 Bodmin NHS Treatment centre considers that this data is as described for the following reasons: Not all patients in the day unit require VTE assessments, but we aim to improve our scores to above 96% in the next year C.Diff rate C. Diff rate: Period Best Worst Average Period Bodmin per 100, /14 Several 0 RMP 32.5 Eng /13 NVC bed days 2014/15 Several 0 RPY 62.2 Eng /14 NVC 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. 5: Treating and caring for people in a safe environment and protecting them from avoidable harm There have been no episodes of C.Diff at Bodmin NHS Treatment Centre. Our aim is to protect all out patients and treat them in a safe environment. Quality Accounts 2013/14 Page 26 of 37

27 Incidents Incident Rate: Period Best Worst Average Period Bodmin Patient Safety A RP6 2.6 TAJ 84.4 Eng /13 NVC /13 RRF 2.0 RAT 85.6 Eng /14 NVC SUIs: Period Best Worst Average Period Bodmin (Severity 1 only) Apr14 - Sep 14 Several 0 RP Eng 0.15 Apr14-Sep14 NVC Oct14 Mar 14 - RD3 0 RJC 1.53 Eng 0.18 Oct14-mar15 NVC 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 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Bodmin NHS Treatment Centre considers that this data is as described for the following reasons; The NRLS does not appear to offer any break down of aggregate figures. Figures are percentage of patient safety events that are severe or death. Bodmin NHS Treatment centre has had no Serious Untoward Events in the past year. Friends and Family F&F Test: Period Best Worst Average Period Bodmin Jan-15 Several 100 RCUEF 72.7% Eng 95.7% Jan 16 NVC24 100% Feb-16 Several 100 RCUEF 74.2% Eng 95.7% Feb 16 NVC24 100% Friends and Family Test - Question Number 12d Staff The data made available by National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation' for each acute & acute specialist trust who took part in the staff survey. 4: Ensuring that people have a positive experience of care Bodmin NHS Treatment Centre did not take part in the national staff survey. Quality Accounts 2013/14 Page 27 of 37

28 3.2 Patient safety We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety. Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators. Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below Infection prevention and control Bodmin NHS Treatment Centre has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 6 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. Quality Accounts 2013/14 Page 28 of 37

29 Infection Rates (percentage of Admissiosns) Infection Rates / / /16 Bodmin NHS Treatment Centre As shown in the graph our infection rate is a little higher than last year but remains very low. Some infections reported occurred more that 14-days after discharge which suggests it is unlikely to be a hospital acquired infection, but we still record them where we are made aware of them so we can have a broader understanding of our patient outcomes Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Bodmin NHS Treatment Centre, 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 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 Quality Accounts 2013/14 Page 29 of 37

30 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. Health and Safety audit was 95% Health and Safety training is provided to all staff annually. Manual handling training provided to all staff annually. 3.3 Clinical effectiveness Bodmin NHS Treatment Centre 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 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 Quality Accounts 2013/14 Page 30 of 37

31 Retrnn to Theatre (Percentage of Admissiosns) specific surgical team. Ramsay s rate of return is very low consistent with our track record of successful clinical outcomes. As seen in the graph below we had very few returns to theatre in 2015/16. Our aim is to have no returns as we did in 2014 and Return to Theatre Score / / /16 Bodmin NHS Treatment Centre 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. Quality Accounts 2013/14 Page 31 of 37

32 Patient experiences are feedback via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy. Feedback regarding the patient s experience is encouraged in various ways via: Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48hrs of a patient making a comment on their web survey Yearly CQC patient surveys Friends and family questions asked on patient discharge We value your opinion leaflet Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/ s Patient focus groups PROMs surveys Care pathways patient are encouraged to read and participate in their plan of care 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 shown in the graph below, although there was a slight drop in satisfaction over the last year 95% is still very high. Our aim is to improve our satisfaction scores over the next year. Quality Accounts 2013/14 Page 32 of 37

33 Satisfaction Scores Satisfaction Scores NHS/Private Patients / /16 Bodmin NHS Treatment Centre Quality Accounts 2013/14 Page 33 of 37

34 Services covered by this quality account Appendix 1 Services covered by this quality account Bodmin NHS Treatment Centre The Treatment Centre opened in January 2006 and is one of ten centres across the UK where Ramsay is working in partnership with the NHS. Ramsay s reputation is built on high standards of in patient care in the private sector. Our aim is to combine this experience of providing quality healthcare with that of our NHS partners. Bodmin Treatment Centre, Boundary Road, Bodmin, Cornwall PL312QT Tel: Registered Manager: Chris Sealey Chris.Sealey@ramsayhealth.co.uk Services Provided Peoples Needs Met for: Treatment of Disease, Disorder Or injury Surgical Procedures Outpatients services Dermatological, Gastroenterology, Gynaecology, General surgery, Maxillofacial / oral, Ophthalmic, Orthopaedic. ENT Ambulatory Day Surgery, Dermatological, Gastroenterology, Gynaecology General surgery, Maxillofacial / Oral, Ophthalmic, Orthopaedic. ENT,Urology All adults 18 yrs and over. All adults 18yrs and over 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 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. All patients must meet social/clinical criteria for day surgery. Quality Accounts 2013/14 Page 34 of 37

35 Quality Accounts 2013/14 Page 35 of 37 Ap pendix 2 Clinical

36 Audit Programme 2016/17 each arrow links to the audit to be completed in each month. Quality Accounts 2013/14 Page 36 of 37

37 Bodmin NHS Treatment Centre 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: Bodmin Treatment Centre on Quality Accounts 2013/14 Page 37 of 37