Duchy Hospital. Quality Account 2013/14. No reported MRSA bloodstream Infections in the past 5 years

Transcription

1 Duchy Hospital Quality Account 2013/14 No reported MRSA bloodstream Infections in the past 5 years

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3 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 2013/14 (looking back) Clinical Priorities for 2014/15 (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 2013/14 Quality Accounts PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 The Core Quality Account indicators 3.2 Patient Safety 3.3 Clinical Effectiveness 3.4 Patient Experience 3.5 Case Study Appendix 1 Services Covered by this Quality Account Appendix 2 Consultants and staff data Appendix 3 Clinical Audits

4 Welcome to Ramsay Health Care UK Duchy Hospital is part of the Ramsay Health Care Group The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals. We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Groups. As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high quality patient care is our number one goal. This relies not only on excellent medical and clinical leadership in our hospitals but also upon an organisation wide commitment to drive year on year improvement in patient satisfaction and clinical outcomes. Delivering clinical excellence depends on everyone in the organisation. It is not about reliance on one person or a small group of people to be responsible and accountable for our performance. It is essential that we establish an organisational culture that puts the patient at the centre of everything we do and as a long standing and major provider of healthcare services across the world, Ramsay has a very strong track record as a safe and responsible healthcare provider and we are proud to share our results. Across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends. We value our people and with every year we set our targets higher, working on every aspect of our service to bring a continuing stream of improvements into our facilities and services. Jill Watts, Chief Executive Officer of Ramsay Health Care UK

5 Introduction to our Quality Account This Quality Account is Duchy Hospitals 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..

6 Part Statement on quality from the General Manager Welcome to Duchy Hospital s quality account. This report outlines the Hospitals approach to quality improvement, progress made in and plans for the forthcoming year. Duchy Hospital 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 Health Protection agency s Surgical Site Surveillance Service and our surgical site infection rates are significantly lower than the national average. 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 establishing an organizational culture that 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. 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 taken part in the NHS Inpatients survey and received excellent feedback. We have also participated in the NHS Friends and Family Survey, and have been delighted with the results and comments received from patients. The Health Gain scores for our joint replacement continue to be amongst the best in the country. In we completed a 6m investment, adding a Cardiac Catheter Laboratory, an additional Laminar Flow Operating Theatre, dedicated state of

7 the art facilities for Day Case patients and refurbishing all of our Reception and Waiting Areas. This has further improved the range of services we can offer, and the quality of service we provide. Chris Sealey General Manager Duchy Hospital Truro

8 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 Duchy Hospital Ramsay Health Care UK This report has been reviewed and approved by: Miss Bates, Consultant Gynaecologist, Medical Advisory Committee Chair Mr Kumaravel, Consultant Ophthalmic Surgeon, Clinical Governance Committee Chairman Helen White, Regional Director, Ramsay Health Care UK Kernow Clinical Commissioning Group Cornwall Overview and Scrutiny Committee Cornwall Health Watch

9 Welcome to Duchy Hospital Duchy Hospital, one of the South West s leading independent hospitals, provides medical and surgical services as outpatient or planned admitted care for adults and older children; the full range of specialties offered is shown at Appendix 1. Where clinical need requires it, our team of well trained, competent and experienced staff provide 1:1 care, Level 2 critical care. In the unlikely event of that a higher level of care becomes necessary, Level 3 Critical Care; there is a transfer arrangement in place with Royal Cornwall Hospitals NHS Trust. Paediatric trained nurses are available to care for those under the age of 18 years. Additional onsite facilities include cosmetics, radiology, physiotherapy, mobile and MRI/CT. We work closely with the Royal Cornwall Hospital NHS Trust which provides our blood transfusion, pathology, and some pharmacy services. On the 24 th April Consultants were registered as approved to practise at Duchy Hospital. The full list of consultants with practising privileges along with a comprehensive list of the disciplines and numbers of staff employed as of April 2014 can be found at Appendix 2. We pride ourselves on the delivery of high quality, safe, effective care in a manner and environment that respects and protects the privacy and dignity of our patients be they medically insured, self-funding or referred by the NHS. Our facilities and clinical and support services are continually monitored to ensure that we are offering the very best service to our patients. Our major capital investment in our facilities came to fruition in summer 2013 and Duchy now has 27 inpatient beds, a purpose built Ambulatory Care facility with 12 patient spaces, 3 laminar flow theatres, a cardiac catheterisation laboratory and outpatient treatment facilities and 11 outpatient consulting rooms. This has enabled us to expand the range of services to patients and to provide them from a modern, well designed environment During the year from 1 st April 2013 to 31 st March ,097 patients received treatment here as day-cases or inpatients of which 5,222 were NHS patients (73%). Of the overall total 5041 (71%) were treated as day cases compared to 69% last year. Only 14% of the day case patients were treated on the inpatient ward compared to 25% in the previous year. This has had a major impact on how efficiently the attendance and stay of these patients is managed.

10 Mrs Miranda Field is our GP Liaison Officer. Miranda has close contact with both the practice managers and the GPs at our practices throughout Cornwall. She organises regular Lunch and Learns, taking Consultants into GP surgeries to offer training and latest development awareness as well as running evening GP training seminars on a regular basis. We value our contact with GPs as customers and strive to ensure we actively work in partnership with them to enhance patient care. Dr Andrew Craze, local GP, is a member of the hospital s Medical Advisory Committee (MAC). The Duchy management team has worked hard to establish a good relationship with Kernow Clinical Commissioning Group which commissions health care services for the people of Cornwall, and looks forward to further developing this relationship during the coming year We work closely with the Royal Cornwall Hospital NHS Trust which provides us with blood transfusion, pharmacy services and access to Level 3 critical care services.

11 Part Quality priorities for 2013/2014 Plan for 2013/14 On an annual cycle, Duchy 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 A review of clinical priorities 2013/14 (looking back) Patient Safety WHO Surgical safety checklist this was also one of our Commissioning for Quality objectives for the year. Compliance with the checklist has been excellent and all of our audits achieve at least 90% with only the absence of small details e.g. times impacting on the score; patient safety was at all times protected Venous-thromboembolism assessment we audited our compliance and results were submitted to UNIFY and national health data base. The results confirm that more than 96.5% of patients were risk assessed where indicated. Never events sadly one Never Event occurred during 2013/14. This involved the implantation of the wrong intra-ocular lens during cataract surgery. The lens was removed as soon as the error was known though this did require a second admission and operation for the patient. They have since made a full recovery JAG accreditation it was only the requirements relating to IT systems that was holding us back. This has been addressed during 2013/14 and our formal accreditation visit will take place in July 2014

12 National Joint Register whilst there was a small dip as a result of staff change over, we have in the main been able to maintain our consistently good scores for data submission to the National Joint Register. Clinical and other training we have continued to achieve good levels of compliance with mandatory training to ensure that patients are cared for by well trained, competent staff. Safeguarding all staff working within the hospital have the appropriate level of CRB check appropriate to their role. Safeguarding Adults and Children E-learning has been completed in accordance with the Ramsay training programme. In addition staff have received a taught session about Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards and PREVENT in accordance with the Ramsay timetable; this is to ensure that staff have the necessary resources available to enable them to manage any concerns appropriately and in a timely manner. Staffing Ramsay invested in an electronic rostering system called Allocate; which was introduced during late Clinical managers have put key staffing requirements and parameters into the system which then produces rotas in line with patient numbers and specific local skill mix requirements. This reduces the time spent on producing numerous rotas throughout the hospital and will be accessible to all staff so they can log in and make requests for leave, training etc. It also records training hours and reminds staff when they need to attend mandatory training sessions. Clinical effectiveness Ambulatory Day Care 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 and the Ambulatory Care Unit has demonstrated this; it continues to be an efficient and effective facility for patients and is a large part of facilitating better outcomes and improving patient experience for those whose procedure does not require inpatient admission Patients appreciate the efficiency of the system which enables them to have their procedure in modern, comfortable surroundings and only have to spend a few short hours in hospital. Pre-operative assessment Clinic (PAC) The capital development provided designated, purpose built space for PAC and Duchy s pre assessment team have continued to work hard to develop the service to ensure patient s fitness for surgery is assessed in advance of their admission to reduce the chance of their operation being cancelled for safety reasons. Our cancellation on the day of surgery for issues relating to patient fitness is very low. During 2014/15 we will continue to improve the efficiency and effectiveness of this service Ramsay is a member of PHIN Private Hospitals Information Network which will enable private providers to benchmark against other types of provider for key performance indicators(activity/volumes, mortality, day case

13 rates, unplanned readmissions, average length of stay, unplanned transfers, reoperations, etc) We have continued to benchmark our services against other providers nationally wherever possible including: VTE risk assessment compliance benchmarking through the national stats website atistics/dh PROMS results benchmarking through national PROMS website. tegoryid-1295 Patient experience Patient reported outcome studies (PROMS) we continued to participate in the national PROMS data collection for Hips, Knees, Varicose Veins and Hernia surgery. The results, which are very encouraging for Duchy, were shared with the medical and clinical staff through the Medical Advisory Committee, Clinical Governance Committee, and Clinical Head of Department and Departmental meetings. Reviewing this data also provides the opportunity to identify poor outcomes and examine practice if and when it exists. Last year we participated in a local Clinical Outcomes tool which was also being piloted by the Royal Cornwall Hospital for orthopaedic patients. This project continues into 2014/15 Patient satisfaction survey Duchy has always achieved a high level of patient satisfaction even during the recent building work. During 2013 the paper based survey was replaced by a web-based questionnaire / telephone survey which allows feedback to be received much more quickly and we receive weekly free-text comments from the survey so we can act in a more timely fashion where necessary. The latest formal report relates to patients discharged during March 2014 and there was a response rate of 65% with a quarterly average response rate of 52.6%. In response to the question Overall how would you rate your experience Duchy achieved a rolling quarter rating of 94.6% and 95.4% of patients said they would recommend the hospital.

14 2.1.2 Clinical Priorities for 2014/15 (looking forward) For 2014/15 Duchy 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. We will monitor this through ratings in the patient survey and national Friends and Family test which is one of our Quality targets in our agreement with Kernow Clinical Commissioning Group (KCCG) for the coming year and will be monitored through our monthly report to them. Develop a pre-optimisation service for patients to enable their complete journey sometimes patients are anaemic or have iron levels lower than is ideal when undergoing major surgery. Currently such patients have to attend other hospitals to resolve this before surgery at Duchy can proceed. This is disruptive for the patient and can lead to unnecessary delays. Increase the number of patients who receive copies of the letter to their GP on discharge. This is important so that patients are fully informed about their care and aftercare. This is one of our quality targets with the KCCG and we will measure it through the patient survey responses. Clinical Effectiveness Improving the effectiveness and consistency of the PAC experience ensuring all patients are assessed prior to admission either by phone or face-to-face and that any health issues that could cause their admission to be cancelled are identified and plans put in place to resolve them so surgery can proceed at the earliest opportunity. All operations cancelled on the day will be recorded and the information analysed to identify if the cancellation could have been prevented Reduce avoidable re-admissions within 30 days of surgery- We will further develop systems for capturing re-admission data including admissions to other hospitals to enable proper analysis of themes, commonalities and make any necessary improvements to practice. Implement a 3-day stay pathway for patients undergoing total hip replacement where this is appropriate. Providing they have the right support, patients recover better in their own homes, and this small reduction in length of stay will help more people go home sooner. Patient Safety We will increase the number of patients who report that staff told them about medication side effects to watch out for when they went home. This is very important so that patients understand their medication and do not suffer unnecessarily from side effects; it is also an area where we rate lower in our patient survey. We will monitor the monthly patient survey results and put actions in place to improve the information given to patients to increase the positive response rate Progress against all of these priorities will be monitored by the Senior Management Team and reported to our local Clinical Governance Committee.

15 Those that are targets agreed with KCCG will also be reported in our monthly quality report to them. 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 Review of Services During 2013/14 Duchy Hospital provided and/or subcontracted 10 NHS Specialties through the Chose and Book system and has reviewed all the data available to them on the quality of care in all of these NHS services. The income generated by NHS services in the year 1 st April 2013 to 31 st March 2014 represents 69.7% of the total income generated from the provision of services by the Duchy Hospital for 1 st April 2013 to 31 st March 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 2013/14, the indicators on the scorecard which affect patient safety and quality were: Human Resources Staff Cost as % Net Revenue HCA Hours as % of Total Nursing Agency Cost as % of Total Clinical Staff Cost Ward Hours PPD % Staff Turnover rolling 12 months % Sickness rolling 12 months % Lost Time Appraisal % Staff Satisfaction Score (max possible 7) Number of Significant Staff Injuries Patient Formal Complaints per 1000 HPD's Patient Satisfaction Score Clinical Events per 1000 Admissions Readmission per 1000 Admissions Quality Workplace Health & Safety Score Infection Control Audit Score % <0.5% % % % 97%

16 2.2.2 Participation in clinical audit During 1 April 2013 to 31 st March 2014 Duchy Hospital participated in 100% national clinical audits it was eligible to participate in. The hospital was not eligible to participate in any of the national confidential enquiries The national clinical audits that Duchy Hospital participated in, and for which data collection was completed during 1 April 2013 to 31 st March 2014, are listed below alongside the number of cases submitted to each audit as a percentage of the number of registered cases required by the terms of that audit or enquiry. Name of audit / Clinical Outcome Review Programme National Joint Registry (NJR) Elective surgery (National PROMs Programme) % cases submitted 86% 82% The reports of two national clinical audits from 1 April 2013 to 31 st March 2014 were reviewed by the Clinical Governance Committee and Duchy Hospital intends to take the following actions to improve the quality of healthcare provided. Improve our systems for submitting data to the NJR Strengthen our systems to ensure all pre-operative PROMS forms are collected and submitted, and that patients understand the importance of submitting their post-operative PROMS questionnaire when it is received Local Audits The reports of 70 local clinical audits from 1 April 2013 to 31 st March 2014 were reviewed by the Clinical Governance Committee and Duchy Hospital intends to take the following actions to improve the quality of healthcare provided. The clinical audit schedule can be found at Appendix 2. All audit results showed a good degree of compliance and our main priority for 2014/15 will be to further improve our standards of documentation Participation in Research Duchy Hospital did not recruit any patients receiving NHS services provided or subcontracted by them to participate in research approved by a research ethics committee in 2013/14. Duchy is working with other providers and local university to enable us to be part of appropriate clinical research projects during 2014/15.

17 2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Duchy Hospital income in from 1 April 2013 to 31 st March 2014 was conditional on achieving quality improvement and innovation goals agreed Kernow Clinical Commissioning Group 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. Agreed goals for 2013/14 Goal Goal Name Description of Goal 1 National Adapted: Venousthromboembolism To reduce avoidable death, disability and chronic ill health from Venousthromboembolism (VTE) Goal weighting (% of CQUIN scheme available) Quality Domain (Safety, Effectiveness, Patient Experience or Innovation) 20% Patient Safety 2 National Adapted: Friends and Family Implementation of the Friends and Family Test in inpatient wards 20% Patient Experience 3 National Adapted: Safety thermometer Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter, and VTE 20% Patient Safety 4 5 Local: MEWS Risk Assessment Local: WHO Surgical checklist Reduce clinical risk to patients by undertaking Medical Early Warning Assessments 20% Patient Safety Compliance with WHO safer surgical 20% Patient Safety checklists. 90% target for all day case and inpatient surgical procedures Totals: % With the exception of one element of goal 4, all goals were achieved

18 Goals for 2014/15 Goal Goal Name Description of Goal Goal weighting (% of CQUIN scheme available) Quality Domain (Safety, Effectiveness, Patient Experience or Innovation) 1 National Friends and Family Test Offer all patients (inpatient,) Implementation of the Friends and Family Test in inpatient wards, day-case unit and outpatients 30% Patient Experience 2 National Adapted: Safety thermometer Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter, and VTE 10% Patient Safety 3 Local: EWS Risk Assessment Reduce clinical risk to patients by undertaking Early Warning Risk Assessments 10% Patient Safety 4 Local: After Care Deliver improved performance in the patient survey in the area of After Care 50% Patient Experience Totals: % Statements from the Care Quality Commission (CQC) The Duchy Hospital is required to register with the Care Quality Commission and its current registration status on 31 st March is registered without conditions. Duchy Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.

19 2.2.6 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 are taken to improve quality as required. This applies to both private and NHS patient streams. The hospital has a data quality super user who manages the SUS pathway processes and continually reviews administration functions to ensure data quality. Duchy Hospital will be taking the following actions to improve data quality. NHS Number and General Medical Practice Code Validity Duchy Hospital submitted records during 2013/14 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included: The patient s valid NHS number: 100% for admitted patient care; 100% for out patient care; and 0% for accident and emergency care (not undertaken at our hospital). The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; and 0% for for accident and emergency care (not undertaken at our hospital). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall score for 2013/14 was 83% and was graded green (satisfactory). Clinical coding error rate Duchy Hospital was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission.

20 2.2.7 Stakeholders views on 2013/14 Quality Account Comments on this Quality account were invited from Kernow Clinical Commissioning Group, Health Watch Cornwall and Cornwall Council Overview and Scrutiny committee Kernow Clinical Commissioning Group Kernow Clinical Commissioning Group is pleased to have the opportunity to comment on the Quality Account 2013/14 for Ramsay Duchy Hospital and welcomes the approach the Hospital has shown in developing and setting out its plans for quality improvement. There are routine processes in place with the Duchy Hospital to agree, monitor and review the quality of services throughout the year covering the key quality domains of safety, effectiveness and experience of care. We have reviewed the report and can confirm the information presented in the Quality Account appears to provide a balanced account which is accurate and fairly interpreted, from the data collected. In terms of the performance against the 2013/14 CQUIN goals the Early Warning Risk Assessment indicators were not achieved in full. The Quality Account presents an overview of a range of quality improvement work being undertaken. We particularly commend the continued high patient satisfaction and patient reported outcome measures and are pleased with the results of the new capital investment which has enabled improvements in the patient pathway and reductions in the average length of stay. We note the positive achievements at the Hospital in the past year such as good control of infection outcomes, improving patient safety by mandating VTE assessments and maintaining high compliance with the WHO surgical safety checklist. We are pleased to see that the priorities chosen for 2014/15 are evidence based and have a continued focus on patient safety and improving the patient pathway. In particular we welcome the continued work on reducing avoidable re-admissions and the new work on reducing preventable cancelled operations by making the pre-operative assessment more efficient. Kernow CCG looks forward to working with the Hospital throughout the year to achieve ever more efficient pathways delivering high quality services to patients. Cornwall Council s Health and Social Care Scrutiny Committee Cornwall Council s Health and Social Care Scrutiny Committee agreed to comment on the Quality Account of Duchy Hospital. All references in this commentary relate to the period 1 April 2013 to the date of this statement. Though during the period identified the Committee have not directly scrutinised the provision of NHS services by the hospital they still wished to comment on the account.

21 Committee Members felt that the Quality Account provided a good reflection of the services provided by the hospital, and provided comprehensive coverage of the provider s services. Heath and Social Care Scrutiny Committee should be made aware of any never events which happen within the hospital Welcome pre-optimisation as long as it is easiest route for the patient The Committee would like to highlight the apparent lack of targets and data for the future clinical priorities. Generic statements such as increase the number of patients receiving copies of letters to their GP do not provide a robust framework on which to scrutinise. The Committee looks forward to future working with Duchy Hospital in Health Watch Cornwall Health Watch Cornwall decided not to comment as it had received very little feedback about your services.

22 Part 3: Review of quality performance 2013/2014 Statements of quality delivery Debby Blease, Matron and Head of Clinical Services Review of quality performance 1st April st March 2014 Introduction This publication marks the fifth successive year since the first edition of Ramsay Quality Accounts. Through each year, month on month, we analyse our performance on many levels, we reflect on the valuable feedback we receive from our patients about the outcomes of their treatment and also reflect on professional opinion received from our doctors, our clinical staff, regulators and commissioners. We listen where concerns or suggestions have been raised and, in this account, we have set out our track record as well as our plan for more improvements in the coming year. This is a discipline we vigorously support, always driving this cycle of continuous improvement in our hospitals and addressing public concern about standards in healthcare, be these about our commitments to providing compassionate patient care, assurance about patient privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open and honest where outcomes and experience fail to meet patient expectation so we take action, learn, improve and implement the change and deliver great care and optimum experience for our patients. Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK Ramsay Clinical Governance Framework 2014 The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation. The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way. It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a stand-alone activity. All management systems, clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others.

23 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.

24 3.1 The Core Quality Account indicators Mortality Period Best Worst Average Period Duchy 2012/13 RKE 0.65 RXL 1.17 Eng /13 NVC /14 RKE 0.63 RBT 1.15 Eng /14 NVC04 0 The Duchy Hospital considers that this data is as described for the following reasons there are very few patient deaths at, or following treatment at this hospital. The Duchy Hospital intends to take the following actions to improve this rate and so the quality of its services maintain a strong focus on pre-admission assessment, and appropriate and effective staff education and competence assessment Re-admission Period Best Worst Average Period Duchy 2010/11 RF4 0.0 RYR 15.8 Eng /13 NVC /12 RF4 0.0 RYR 15.8 Eng /14 NVC The Duchy Hospital considers that this data is as described for the following reasons there is a safe discharge policy in place and patients are given good aftercare instructions The Duchy Hospital intends to take the following actions to improve this rate and so the quality of its services maintain a system of comprehensive patient assessment and information PROMS Hernia Period Best Worst Average Period Duchy Apr12 - Apr12 - NT NVC Eng Mar13 Mar13 NVC04 Apr13 - Apr13 - RTG RNA Eng Sep13 Sep13 NVC04 Duchy Hospital considers that this data is as described for the following reasons the number of hernia procedures is too small for the Duchy to participate Duchy Hospital intends to take the following actions to improve this it will monitor the amount of hernia procedures and subscribe if the numbers become sufficient

25 Veins Period Best Worst Average Period Duchy Apr Apr12 - RV NT Eng Mar Mar13 NVC04 * Apr13 - Apr13 - RTD RLN Eng Sep13 Sep13 NVC04 Duchy Hospital considers that this data is as described for the following reasons the number of veins procedures is too small for the Duchy to participate Duchy Hospital intends to take the following actions to improve this it will monitor the amount of veins procedures and subscribe if the numbers become sufficient Hips Period Best Worst Average Period Duchy Apr12 - Apr12 - NT RKE Eng Mar13 Mar13 NVC Apr13 - Apr13 - NT RHQ Eng Sep13 Sep13 NVC Duchy Hospital considers that this data is as described for the following reasons patients report good outcomes when returning for follow-up we have good systems for ensuring pre-op questionnaires are returned and patients understand the importance of returning their post-op questionnaire Duchy Hospital intends to take the following actions to improve this to continue and further improve return rates to ensure patients have realistic expectations and appropriate rehab. Knees Period Best Worst Average Period Duchy Apr12 - Apr12 - NT RAP Eng Mar13 Mar13 NVC Apr13 - Apr13 - RDE RM Eng Sep13 Sep13 NVC04 * Duchy Hospital considers that this data is as described for the following reasons patients report good outcomes when returning for follow-up we have good systems for ensuring pre-op questionnaires are returned and patients understand the importance of returning their post-op questionnaire Duchy Hospital intends to take the following actions to improve this to continue and further improve return rates to ensure patients have realistic expectations and appropriate rehab

26 Readmissions Period Best Worst Average Period Duchy 2011/12 RYR 73.3 RF Eng /13 NVC /13 RYR 75.9 RJ Eng /14 NVC Duchy Hospital considers that this data is as described for the following reasons we have robust clinical pathways which include discharge criteria discharge planning and the decision to discharge are based on individual needs and condition Duchy Hospital intends to take the following actions to improve this to improve our awareness of readmissions to other hospitals to continue to ensure patients are only discharged when it is safe and with the proper advice/back-up Responsiveness to personal needs Period Best Worst Average Period Duchy 2011/12 RYR 73.3 RF Eng /13 NVC /13 RYR 75.9 RJ Eng /14 NVC Duchy Hospital considers that this data is as described for the following reasons we provide excellent customer service as demonstrated by patient surveys care is planned on an individual basis Duchy Hospital intends to take the following actions to improve this to continue to ensure patients remain the focus of all we do VTE Assessment Period Best Worst Average Period Duchy 13/14 Q3 Several 100% NT % Eng 95.8% 13/14 Q3 NVC % 13/14 Q4 Several 100% NT % Eng 96.0% 13/14 Q4 NVC % Duchy Hospital considers that this data is as described for the following reasons our clinical pathway documents direct staff to undertake VTE Risk assessment staff understand the importance of VTE Risk Assessment Duchy Hospital intends to take the following actions to improve this to continue to undertake local audit and ensure risk assessment is completed where indicated, and patients receive appropriate prophylaxis C. Diff rate per 100,000 bed days Period Best Worst Average Period Duchy 2012/13 Several 0 RNA 58.2 Eng /13 NVC /14 Several 0 RVW 30.8 Eng /14 NVC Duchy Hospital considers that this data is as described for the following reasons the hospital has an excellent record in infection prevention and control assessment

27 there is low use of anti-microbials and any prescribing is in line with national best practice and the CCG Formulary Duchy Hospital intends to take the following actions to maintain this to continue to provide staff, patients and visitors with education and information about good infection prevention and control practice continue as an active participant in local and national infection control forum Incident rate, patient safety Period Best Worst Average Period Duchy 2011/12 RP6 2.6 TAJ 84.4 Eng /13 NVC /13 RRF 2.0 RAT 85.6 Eng /14 NVC Duchy Hospital considers that this data is as described for the following reasons we provide elective care only and are therefore able to risk assess and provide patients with an appropriate environment there are procedures and processes in place to ensure safe practice and care Duchy Hospital intends to take the following actions to maintain this to continue to analyse patient safety incidents to identify areas where the environment or practice can be further improved ensure that our environment is well maintained and risk assessments are in place where there is cause for concern Friends and Family Test Period Best Worst Average Period Duchy Jan-14 Several 100 RPA02 27 Eng /13 NVC04 96 Feb-14 Several 100 RPA02 18 Eng /14 NVC04 93 Duchy Hospital considers that this data is as described for the following reasons actively encourage patients to complete the F&F test, and have systems in place to facilitate them doing so the hospital has an established reputation for high quality care and customer service Duchy Hospital intends to take the following actions to maintain this to continue to and facilitate patients in the completion of the test to extend the test to outpatients and those who attend for day case procedures 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.

28 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 Duchy Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 5 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: All staff receive education and training in IPC and Hand-washing. In addition clinical nurses undertake further training and assessment of competence assessment in Aseptic No Touch Techniques (ANTT) The cleanliness of the hospital is audited regularly as part of the Ramsay corporate clinical audit programme as well as regular monitoring by Matron, the Operations Manager and other members of the local senior management team There is a real focus on wearing uniform and protective clothing properly and appropriately We have introduced hand gel dispensers on every patient bed and at the entrance to clinical departments The Hospital Infection Control Committee meets regularly and reports to the Clinical Governance Committee as well as the corporate IPC Committee. All staff take their responsibility for preventing infection seriously

29 As shown in the graph our already low infection rate has reduced even further during the year despite the hospital treating more patients and employing more staff year on year Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Duchy 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. The NHS England chart below shows the four domains of the assessment with Duchy scores as the thermometer compared to the national average as a green bar by its side

30 Duchy is very proud that we were above average in all domains but continue to strive to improve Safety in the workplace Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. Activities during 2013/14: All incidents are recorded on our electronic reporting system RiskMan and analysed by our Clinical Governance and Risk and Safety committees to identify areas for action. We have replaced all of hydraulic patient beds with electric ones. This provides greater control for patients and reduces moving and handling for staff Additional moving and handling equipment has been purchased including patient slide sheets and straps Internal floor coverings have been replaced and external paths and car parking areas have been resurfaced to further reduce Slip, Trip Falls. Staff continue to receive training in risk assessment, moving and handling and Fire and Security 3.3 Clinical effectiveness Duchy 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.

31 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 consistent with our track record of successful clinical outcomes. As can be seen in the above graph our return to theatre rate has increased a little over the last year but the numbers are still very low. The increase may be a reflection of the increasing complexity of the procedures we now undertake. Each return to theatre has been reviewed to see if there are trends or commonalties, and we have not found any; the returns are attributable to a number of specialties, and various times of day/day of week but most are accepted risks of the various procedures. In all cases the patient made a full recovery. We will continue to monitor all returns to theatre and take any action indicated as necessary 3.4 Patient experience All feedback from patients regarding their experiences with Ramsay Health Care is welcomed and informs 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.

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 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 can be seen in the above graph our Patient Satisfaction rate has been maintained over the last year despite significant disruption due to the presence of contractors onsite and building works.

33 All staff endeavour to deliver a positive experience for everyone visiting the hospital or using its services. Now the building work is complete, we hope to see an improvement in satisfaction during the coming year. 3.5 Duchy Hospital Case Study Following the completion of our recent investment in facilities we invited a small group of patients to conduct a Patient Led Assessment of the Care Environment (PLACE). We spent time with these patients who then carried out their assessment and gave us comprehensive feedback. As a result of the feedback we were able to make some changes to our external and internal facilities, such as improving disabled parking, improving our entrance ramp, minor changes to some of our toilet facilities. We are committed to continuing to engage with patients, consultants and other stakeholders to continually improve our facilities, services and patient experience.

34 Appendix 1 Services covered by this quality account Duchy Hospital. Duchy Hospital has 27 beds and an Ambulatory Care Unit with 12 patient spaces. The Hospital has 3 theatres with laminar flow and a fully equipped endoscopy unit, plus a Cardiac Catheter Laboratory. Patients requiring level 2 care are treated and cared for by a well trained team of staff in individual rooms. All Ramsay Health Care UK Hospitals have transfer agreements in place either with their local trust or critical care network. Duchy Hospital provides NHS consultations for those over the age of 18 but holds CQC registration for all age groups. On site facilities include Outpatients, Cosmetics, Radiology, Angiography Physiotherapy and Mobile MRI/ CT. Our clinical facilities are continually monitored to ensure that we are offering the very best service to our patients. Regulated Activities Duchy Hospital Treatment of Disease, Disorder Or injury Surgical Procedures Services Provided Physiotherapy, Cardiology, Endocrinology, General medicine, Haematology, Oncology, Neurology, Psychiatry, Psychotherapy, Speech therapy, Sports medicine, Urology, Medicine management, Clinical neuro, physiology, Allergy testing, Diabetology, Occupational therapy Cosmetic, Bariatrics, Dermatological, Ear, Nose and Throat (ENT), Gastrointestinal, Colorectal, Breast surgery, General surgery, Gynaecological, Ophthalmic (inc laser), Maxillofacial / oral, Orthopaedic, Urological, Peoples Needs Met for: All adults 18 yrs and over All children 12 yrs and over Consultations from birth All adults excluding: Patients with complex blood disorders (haemophilia, sickle cell, thalassaemia) Patients on renal haemodialysis

35 Diagnostic and screening Diagnostic and screening Neurological, Ambulatory, Day and Inpatient Surgery Cardio physiology, ERCP, GI physiology, Imaging services, Phlebotomy, Urinary Screening and Specimen collection Imaging services, Phlebotomy, Urinary Screening and Specimen collection. 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 adults 18 yrs and over All children 12 yrs and over Consultations from birth All adults 18 yrs and over Children 3 years and above

36 Appendix 2 - Consultants and employed staff. 142 Consultants were approved to work from Duchy at 23 rd April 2014 Title Initital Surname Specialty Title Initital Surname Specialty Mr S Adcock Facio-maxillary Surgeon Dr K Kandasamy Cardiologist Mr S Ahmad General Surgeon Mr R Kincaid Orthopaedic Surgeon Mr A Al-Shawi Orthopaedic Surgeon Mr S Kumaravel Ophthalmologist Mr P Arumugam General Surgeon Dr R Langford Anaesthetist Dr S Banks Anaesthetist Mrs N Lansley Family Psychotherapist Mr G Bartlett Orthopaedic Surgeon Mr C Lansley Facio-maxillary Surgeon Miss S Bates Gynaecologist Mr A Lee Orthopaedic Surgeon Dr J Bebb Gastroenterologist Mr E Lloyd- Davies General Surgeon Dr J Beckly Gastroenterologist Miss F Lone Gynaecologist Dr H Belcher Radiologist Dr T W Lucke Dermatologist Dr J Berry Anaesthetist Dr F Luscombe Anaesthetist Dr C V Blacker Psychiatrist Dr N Marshall Anaesthetist Mr C Blake Urologist Dr G Maskell Radiologist Dr J Boyden Anaesthetist Mr J Matthews Orthopaedic Surgeon Mr D Bracey Orthopaedic Surgeon Dr R Mawer Anaesthetist Mr I Brown Breast Surgeon Mr J McDiarmid Plastic Surgeon Dr D Browne Endocrinologist Mr P McGannity Dentist (Implant) Mr M Butler Orthopaedic Surgeon Dr B McLean Neurologist Mr D Byrne Gynaecologist Dr N Michell Gastroenterologist Dr P Carpenter Anaesthetist Dr K Mitchell Anaesthetist Mr H Chant Vascular Surgeon Dr S Mohammed Radiologist Dr T Chave Dermatologist Dr A Moore Anaesthetist Dr J Cheung Anaesthetist Mr R Morris Plastic Surgeon Ms K Claridge Ophthalmologist Mr N Munro Urologist Dr P Cook Radiologist Dr J D Myers Physician Mr R Cox Urologist Mr M Norton Orthopaedic Surgeon Dr A Craze General Practitioner Dr P Owens Cardiologist Dr D Creagh Haematologist Dr J Paddle Anaesthetist Mr J Dainton Orthopaedic Surgeon Mr H J Parker Oral Surgeon Dr H Dalton Gastroenterologist Dr RG Parry Physician Mr J Davies Vascular Surgeon Mr S Parsons Orthopaedic Surgeon Dr M Davis Rheumatologist Mr A Patwardhan Ophthalmologist Dr J M De Beer Anaesthetist Mr P Peyser General Surgeon Dr A Dingwall Anaesthetist Dr A Pickford Anaesthetist Dr P Divekar Dermatologist Prof J Pinkney Physician Mr S Dixon Orthopaedic Surgeon Mr R Poulter Orthopaedic Surgeon Prof P Drew Oncoplastic Breast Surgeon Dr C Powell Anaesthetist Dr A Edwards Radiologist Dr M Proctor General Practitioner Dr D Elliott Anaesthetist Dr A Rajasri Obstetrics & Gynaecology Dr R Ellis Oncologist Mr M Regan Orthopaedic Surgeon Dr W English Anaesthetist Mr T Scott Orthopaedic Surgeon Dr S Evans Cardiologist Dr R Searle Anaesthetist Dr K D Farmer Radiologist Mr S Sexton Orthopaedic Surgeon Mr J W Faux General Surgeon Dr D J Sim Anaesthetist

37 Title Initital Surname Specialty Title Initital Surname Specialty Mr D Fern Orthopaedic Surgeon Dr A Simaitis Cardiologist Mr I Finlay General Surgeon Dr T Skinner Anaesthetist Dr W Fish Anaesthetist Dr A Slade Cardiologist Mr A Fitton Plastic Surgeon Dr G Smith Neurologist (Medico Legal Only) Mr P Flanagan ENT Surgeon Mr I Smith ENT Surgeon Dr P Fortun Gastroenterologist Dr M Spivey Anaesthetist Dr Z Freeman General Practitioner Dr W Stableforth Gastroenterologist Mr T Germon Surgeon Mr N Sudhakar Neurosurgeon Dr S Gray General Practitioner Dr T Sulkin Radiologist Dr J Hancock Radiologist Dr R Taylor Anaesthetist Dr S Hann Dermatologist Dr H Thompson Anaesthetist Dr A Harvey Anaesthetist Dr A Thomson Oncologist Dr W R Harvey Anaesthetist Dr S Thorogood Radiologist Mr B Holland Optician Dr M Thorpe Paediatrician Dr N Hollings Radiologist Dr R Van Lingen Cardiologist Mr R Holmes Gynaecologist Dr P Waterhouse Anaesthetist Mr N Hopper Vascular Surgeon Mr D Weerasirie Dental Surgeon Dr P Hopton Anaesthetist Mr W Westlake Ophthalmologist Mr M Hotston Urologist Ms A Wheeler Dietitian Dr H Hussaini Gastroenterologist Mr D Whinney ENT Surgeon Dr D Hutchinson Rheumatologist Mr A Wilde ENT Surgeon Dr J Hyslop Radiologist Mr D Williams Orthopaedic Surgeon Dr W E Jewell Anaesthetist Mr N Wilson-Holt Ophthalmologist Dr R T Johnston Cardiologist Mr K R Woodburn Vascular Surgeon Mr D Jones Ophthalmologist Dr W Woodward Anaesthetist Our Total employed staff complement as of April 2014 is 186 made up of: Physio & Occupational Therapists 16 Porters 8 Nurses/ ODP s 59 Admin Staff 49 HCA s 18 Hotel Services 16 Radiographers 4 TSSU 3 Catering 7 Maintenance 4 Supplies 2 Quality Accounts 2013/14 Page 37 of 39

38 Appendix 3 Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month. Quality Accounts 2013/14 Page 38 of 39