North Downs Hospital. Quality Accounts 2015/16

Transcription

1 North Downs Hospital Quality Accounts 2015/16

2 Contents Welcome to Ramsay Health Care UK 3 Introduction to our Quality Account 4 PART 1 - STATEMENT ON QUALITY 1.1 Statement from the General Manager Hospital accountability statement Welcome to North Downs 7 PART Priorities for Improvement Review of Clinical Priorities 2015/16(looking back) Clinical Priorities for 2016/17 (looking forward) 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 22 PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 Statements of Quality delivery The Core Quality Account indicators Patient Safety Clinical Effectiveness 3.5 Patient Experience Appendix 1 Clinical Audits Page 2 of 41

3 Welcome to Ramsay Health Care UK North Downs 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, and the Clinical Commissioning Group. 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. Statement from Mark Page Chief Executive officer Ramsay Health Care UK Page 3 of 41

4 Introduction to our Quality Account This Quality Account is North Downs 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 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 41

5 Part Statement on quality from the General Manager As the General Manager of North Downs Hospital I am passionate about the delivery of high standards of care to all our patients. An effective organisational structure is in place which contributes to the provision of this service. North Downs Hospital works closely with Consultants and patients to ensure the best quality care is received. To ensure we have a co-ordinated approach to the delivery of the care we provide, we have a Clinical Governance Committee and a Medical Advisory Committee, both of which monitor adherence to professional standards and legislative requirements. These Committees also review the Hospital s clinical performance. Our hospital staff are fully trained in the procedures undertaken and also in more general areas such as Customer Care. As General Manager of North Downs Hospital, I take great pride in the service we offer our patients and relatives; this is only achieved through a cohesive approach and team effort. North Downs Hospital s Vision Statement is to be a leading provider of health care services by delivering high quality outcomes for patients and ensuring long term business security. We will actively seek ways to improve the performance of our Hospital. This vision is reflected throughout the Quality Report in that the Hospital will constantly strive to improve the quality and suitability of its services to patients by ensuring there are adequate core policies and skills, effective feedback mechanisms on the quality and efficacy of its activities and processes in place to affect improvement at all levels of the organisation. Our Quality Account details the actions that we have taken over the past year to ensure that our high standards in delivering patient care remain our focus for everything we do. Through our robust audit regime and by listening to our stakeholders, including patient feedback, we have been able to identify areas of good practice and where we can improve the care patients receive. This has enabled us to refine some of our processes to make improvements to the service we offer our patients. In preparing this report, the hospital has taken into account the views of a wide range of stakeholders in the hospital s activities, including staff, Consultants and the Ramsay Corporate Team. Furthermore, you are invited to feedback on this document by sending any comments in writing to me at the hospital. Monica Clarke General Manager, North Downs Hospital Page 5 of 41

6 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. Monica Clarke General Manager North Downs Hospital Ramsay Health Care UK This report has been reviewed and approved by: Mr Khalid Drabu, Orthopaedic Consultant and Chair of the Medical Advisory Committee Dr Barbara Bray, Consultant and Chair of the Clinical Governance Committee Mr Mark Bounds, Regional Director South Page 6 of 41

7 Welcome to North Downs Hospital North Downs Hospital was established 42 years ago and is one of Surrey s leading private hospitals. Located in a quiet residential area of Caterham, it provides a comprehensive range of surgical and medical services together with the highest standards of patient care. North Downs Hospital retains its reputation for delivering such care in a welcoming, clean and comfortable environment. The hospital is regulated by the Care Quality Commission; our latest report can be viewed at or by request to the General Manager. The hospital is well led with a robust governance and risk management framework in place. Staff are given the opportunity to engage with the Senior Management Team and feel supported and listened to. The hospital invests in all staff, ensuring they have the relevant training and skills to be effective in their role. The hospital has access to online training, webinars and the Ramsay Academy. This provides strategic and consistent training provision across the organisation. The hospital has systems in place to keep our patients safe, including processes for reporting incidents with robust investigations and shared learning. Evidence based assessments, care and treatment is delivered to patients following national guidance by qualified and competent staff. Outcomes for patients are monitored on an ongoing basis to ensure that treatment is effective. We have a dedicated workforce that is committed to making each and every patient feel safe and secure. Whether our patients are attending a consultation, day surgery or undergoing a major procedure we want them to feel that they are cared for by compassionate and highly trained staff that provide skilled care 24 hours per day. Over the past 42 years our establishment has grown from strength to strength. From our friendly Page 7 of 41

8 reception staff to our highly skilled surgeons, patient care and their opinions are what matters most; and our positive feedback from our patients gives our entire team great pride. The service is supported by two longstanding Resident Medical Officers providing 24 hour cover for patients. The facility currently has 16 individual and 1 double inpatient bedrooms, all with en-suite facilities to ensure complete privacy. We also have a 5 bay day procedure facility. Ramsay Health Care has invested in advanced medical technology, particularly in our operating theatres, and offers a wide range of treatments and services. We have two operating theatres, one with laminar flow. The out-patient department consists of four consulting rooms with a minor procedures room. Our pre-assessment team ensure a risk based approach to individual patient assessment. We have a well-equipped physiotherapy department providing specialist physiotherapy services which include orthopaedic, sports injury, hand therapy, women s health and acupuncture. We also have Physiotherapy and Radiology departments. Other services which include MRI, CT and Dexa scans are provided by our sister hospital in Ashtead. We have a close relationship with Surrey & Sussex NHS Trust who provide us with blood transfusion and other pathology services (we are able to carry out a range of point of care tests (POCT) on site). Additional pathology services including histology are provided by Spire Gatwick Park Hospital. We also work closely with Croydon Health Services NHS Trust. Both Trusts provide us with access to Level 2/3 critical care services as required. We are a member of the Surrey Wide Critical Care Network. Services provided at North Downs Hospital include both medical and surgical specialities including: Orthopaedics, Endoscopy (JAG accredited), General Surgery, Ophthalmology, Dermatology, ENT, Cosmetic Surgery and Gynaecology. We have established a good relationship with local CCG s to provide a wide range of services to meet the needs of the local healthcare community. We continue to work collaboratively to ensure that patients can have treatment at their local hospital where appropriate. We take great pride in our ability to innovate and develop new ways of working, ensuring that all care is delivered in the best and most efficient way. We have a total of 85 Consultants and 35 Anaesthetists who practise at North Downs. All our consultants undergo rigorous vetting procedures prior to commencing practice at the Page 8 of 41

9 hospital and regular review through our clinical governance framework to ensure the highest possible clinical care. Total number of patient admissions in the last year to April was 3752 of which 2835 were NHS patients. Our staff compliment as of April 2015 is 55.9 WTE and 22 bank members of staff. Qualified Nurses 11.9 WTE HCA 5.9 WTE Radiographers 1.4 WTE Porters 1.7 WTE Administration staff 21.7 WTE Support Services 7.6 WTE Operating Department Practitioners 5 WTE Our pharmacy, decontamination and supplies services are provided by Ashtead Hospital. Our Business Office and Accounting functions work across both sites. Having this close working relationship ensures that we regularly share best practice. We continue to host regular open events which offer an opportunity for the public to view our facilities whilst finding out about a specific subject of interest. Our GP Liaison Officer visits local GP surgeries to regularly update practise staff on our services and assist them with any issues. We also run GP education seminars. Our NHS Services Directory is frequently updated and redistributed to the GPs to ensure that information is always current. We have always valued our contact with GPs as customers and strive to ensure that we actively work in partnership in the best interests of the patients and their families. North Downs continues to score highly regularly receiving scores of between % on the Friends & Family feedback with exceptional comments regularly received from patients. North Downs Hospital continues to innovate and is currently considering options to further develop the ophthalmology services with support from the corporate business development team. Page 9 of 41

10 Part Quality priorities for 2015/2016 On an annual cycle, North Downs Hospital develops an operational plan to set objectives for the year ahead. We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services. To meet these aims, we have various initiatives ongoing at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital A review of clinical priorities 2014/15 (looking back) Patient safety Hand Hygiene We continue to support the relevant clinical staff with ANTT training which is incorporated within their IV update. Hand hygiene has remained a high priority focus area throughout the last year and we now have patient information leaflets distributed in all the departments. As a result of some low scoring in our patient perceptions of healthcare staff washing their hands, we have increased the number of alcohol gel stations throughout the hospital and have strategically placed one at Reception whereby the Reception staff are prompting all visitors entering the hospital to use this. There is a focus on Hand Hygiene within the mandatory training programme for all staff and awareness is raised for both staff and visitors at the Hand Hygiene Awareness Day. Page 10 of 41

11 Patient feedback is reviewed on a regular basis through various forums and we continuously maintain this as a key focus. Hand Hygiene audits over the last year have scored consistently high at 99% Patient Discharge Medication patients taking analgesic medicines home are now issued with a leaflet which helps them to assess their levels of pain and understand which painkiller may be most appropriate for their requirements. We had previously recognised that an increase in our Pharmacy hours input would also aid this process and to that effect we now have a Pharmacist on site 4 days a week. Care of patients with Dementia or patients requiring memory support Over the last year we have worked closely with the CCG and have improved our levels of screening for patients of 75 years and over with the 6CIT Cognitive Impairment Test and onward GP referral for those who score above the threshold. External training has been provided for key members of staff with supplementary e- learning support also. Patients with memory difficulties are identified at Pre-assessment and this is communicated to the relevant departments via an advanced notification form. We have also implemented a blue pillowcase scheme whereby any patient requiring support with memory can be easily identified in a sensitive manner by all members of staff. There is additional literature displayed in the Outpatient Department from the Alzheimer s society for patient information. Our Dementia Champion will be leading a project to improve the pathway for patients with Dementia in the coming year. Clinical Effectiveness Ambulatory Care We have continued to work closely with all stakeholders in relation to improving this pathway. As we see areas for further development we will address with the relevant teams. We continue to stagger admission times and monitor patient wait times. We will collaborate with the CCG on new pathway options such as direct access services. Improving Medical Records workflow North Downs is a trial site for the new Electronic Patient Record system which is now being rolled out in September The new format aims to improve the patient experience as well as ensuring that records are kept in accordance with national guidance. The teams are continuing to participate in training and webinars in preparation for the go live. Page 11 of 41

12 Patient Experience We have amended the structure of our patient feedback group and invite patients to attend to participate in discussing their experiences, whether good or bad, and giving their view on how we may improve the patient journey. North Downs sees the value of feedback and places emphasis on continuous improvement. Improving the nutrition and hydration of our patients: North Downs prides itself on providing a high standard of healthy, nutritional food to our patients and our patient feedback over the last year demonstrates this: Great service and the food is good. The food was nicely cooked and presented. Chef very flexible in meeting my specific requirements. Homemade cottage pie excellent Enjoyed the good quality food. - Source: Friends and Family December 2015 Several key initiatives have been undertaken over the last year in relation to improving the nutrition and hydration of patients. Ward nursing staff have completed nutrition and hydration e-learning and the Head Chef has successfully completed the Chartered Institute of Environmental Health Level 2 training in healthier food and special diets. We have also placed a focus with our patients on the importance of being well hydrated not only peri-operatively but also when they go home, in line with NICE guidance. Supportive literature has been devised with this in mind which is given out to patients. We are able to tailor our menu to meet the specific needs of individual patients at the different stages of their pathway Clinical priorities 2016/17 (looking forward) Patient safety Safety Standards 2015/16 has seen the theatre team build on their safety culture. Monthly clinical audits are completed to review clinical safety and effectiveness. The average compliance rate for these audits during 2015/16 was above 96%. Page 12 of 41

13 Our theatre have worked consistently to improve compliance against the WHO checklist principles and we are now looking to extend this project to cover all invasive procedures wherever they are undertaken in the hospital. The National Safety Standards for Invasive Procedures, (NatSSIPS) will provide the framework for development of LocSSIPS (local safety standards) which will underpin practice within the outpatient and radiology departments as well as the operating theatres. The introduction of these standards will help ensure that surgical Never Events are prevented. A small working party will be established to work in collaboration with the Ramsay Clinical Practice Development Committee to develop the tools required. Management of Risks Risk assessment is a key priority when considering patient safety. We currently carry out risk assessments in individual departments within the hospital, these being reviewed at the relevant Health & Safety or governance forums. There is currently a separate Risk Register which identifies business risks. In order to facilitate full oversight of the risks identified within the hospital we will be amalgamating all risks assessments into one document. The SMT will devise a comprehensive action plan which will be reviewed on a regular basis. Clinical Effectiveness Medication Safety Thermometer This is a measurement tool to aid improvement, focusing on medication reconciliation, allergy status, medication omission, and identifying harm from high risk medicines. We have recently introduced this point of care survey and although it is too early to identify any trends we will be working to ensure full compliance and prompt MDT referral where triggers occur. Having recognised the need for increased pharmacist input we have continued to increase our resources and this will assist us in meeting our aim to ensure harm free care for our patients. Diabetic pre-op fasting pathway We recognise the specific needs of this patient group and following a review of our current practice and discussion with the CCG we plan to introduce an individualised targeted pathway for patients who are admitted for surgery. An initial training needs analysis will be used to identify the needs of different teams within the hospital. A multi-disciplinary team will be established to devise the pathway and our diabetes champion will ensure that all patients admitted are assessed and treated in accordance with the agreed protocol. Page 13 of 41

14 Patient Experience Patient experience continues to be a key focus that underpins every priority at North Downs Hospital. Fostering an environment that enables us to learn and respond to patient feedback is critical to the growth and development of our services. We intend to continue to monitor patient feedback in order to build upon the patient experience at North Downs Hospital. We pride ourselves on delivering a high standard of care for all our patients and intend to continue to provide a first class service. Our aim is to ensure that a member of the Senior Management Team visits our inpatients on a daily basis. Satisfaction will continue to be monitored through patient feedback and complaints. We aim to continue to improve care through learning and listening, responding to patients needs and concerns. This will be monitored monthly through regular meetings and reports. We aim to introduce information boards to display the results from patient feedback and highlight the responsiveness. North Downs will continually strive to build upon and improve facilities for our customers and outside stakeholders. The hospital is continuing to invest in refurbishing the facility with essential updating of our Outpatient consulting rooms, development of the Ophthalmology services whilst our dedicated Cosmetic Surgery Lead is working with the Consultants to build on our current Cosmetic service. Care of patients with Dementia or patients requiring memory support Further to the initiatives of 2015/16, we are keen to progress with the care pathway of this patient group and their families/carers. We aim to identify dementia champions in all departments who will ensure that patients receive the appropriate care throughout their journey. We will undergo a review of equipment/devices that will aid this patient group with an ultimate aim of creating a dementia friendly room for patients and carers requiring a hospital stay. We will increase our networking with local agencies and community support to gain further insight into how we care for this patient group. Page 14 of 41

15 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 The income generated by the NHS services reviewed in 1 April 2015 to 31st March 2016 represents 65% of the total income generated from the provision of NHS services by the North Downs for 1 April 2015 to 31st March During 2014/2015 North Downs Hospital provided 23 NHS services. North Downs Hospital has reviewed all the data available to them on the quality of care in 23 of these NHS services. Regulated activities (Adults Only): Treatment of Disease, Disorder or Injury: Aesthetics, Cardiology, Dermatology, Colorectal, Endocrinology, Fertility, Family Planning, Gastrointestinal, General Medicine, Gynaecological, Neurology, Nurse led sclerotherapy, Ophthalmology, Pain Management, Physiotherapy, Podiatry, Psychiatry (OPD only), Rheumatology, Sexual Health, Sports Medicine, Urology, Vascular Surgical Procedures: Ambulatory, Cosmetic, Colorectal, Dermatology, Ear, Nose and Throat (ENT), General Medicine, General Surgery, Gynaecological, Ophthalmology, Orthopaedic, Pain Management, Podiatric surgery, Urology, Vascular, Day & Inpatient Surgery Diagnostic and Screening: GI Physiology, Endoscopy, Allergy Testing, Imaging services, Phlebotomy, Urinary Screening (including Urodynamics) and specimen collection Ramsay uses a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year. The scorecard is reviewed each quarter by the hospitals senior managers together with regional and Corporate Managers. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement. This data is also a useful tool for other Heads of Department who can measure their performance in a number of areas with their peers at other hospitals of a comparable size. In the period for 2015/16, the indicators on the scorecard which affect patient safety and quality were: Page 15 of 41

16 Human Resources Indicator Outcome HCA Hours as % of Total Nursing Hours 18% Agency Hours as % of Total Hours 4.5% % Staff Turnover 12.6% % Sickness 5.1% Total Lost Worked Days 1580 Appraisal % 35% Mandatory Training 76% Number of Significant Staff Injuries 0 There were no RIDDOR events reported in 2015/16. In 2015/2016 our expectation was to continue to recruit to any permanent positions and maintain the excellent rate of retention of permanent staff in order to maintain a low percentage of agency use. This has proved a challenge in the current climate where the demand for nursing and ODP staff is high; however 2016 has seen an increase in North Downs recruiting to some key positions and it is our aim over the next year to reduce our use of agency staff. The hospital delivers an internally held Mandatory Training Programme for all staff members, including clinical and non-clinical. Staff attendance is recorded to ensure compliance. The training is instigated on a monthly basis throughout the year. Patient Indicator Outcome Formal Serious Complaints per admissions Patient Satisfaction Score 95.2% Number of Significant Clinical Events 2.14 per 1000 admissions Number of Readmissions per admissions Complaints are reviewed by the Clinical Governance Committee and Medical Advisory Committee on a regular basis. Lessons learned from complaints are discussed at departmental meetings to offer staff an opportunity to reflect on the complaint and as a team identify where improvements could be made. Patients are now increasingly invited to Page 16 of 41

17 meet with the General Manager and Quality Lead to discuss their complaints/experiences and this has demonstrated that face to face interaction is a far more useful tool in dealing with these situations. North Downs Hospital utilises patient surveys to assimilate unbiased data from patients about their experience and satisfaction with the services they have received. Our webbased independent company, Qa Research releases data on a monthly basis which is reviewed by the Senior Management Team and at appropriate forums to identify areas for improvement and formulate action plans accordingly. Feedback from our patients is important to us and based on the feedback for the last quarter of 2015, our average compliance score was over 90% in the following areas: Friendly welcome100% Offered a choice of food 100% Received answers from a doctor that they could understand 99% Given enough privacy 99% Involved in decisions about their care 97% Treated with respect and dignity 99% Cleanliness of room 94% Enough nurses on duty 96% There are two key measures of satisfaction; likely to recommend and overall satisfaction. North Downs received over 90% for both these areas. Another mechanism whereby we can act on patient feedback is via the Hot Alert system. This is web-based feedback which allows patients to comment on any aspect of their stay. All Hot Alerts are reviewed by the General Manager and are responded to accordingly. North Downs also participates in the NHS Friends and Family scheme. This is a simple tool for both NHS and private patients to comment on their visit to North Downs. North Downs scores consistently highly in this area: Source: F & F Dec 2015 Page 17 of 41

18 Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. For further details please visit: North Downs has had no Never Events during the past year. Quality Indicator Outcome Workplace Health and Safety Score 85% Infection Control Audit Score 97% Staff Satisfaction surveys have been completed during the year with an engagement score of 72% which is extremely encouraging. Action plans as a result of the survey will be generated via our Employee Engagement Action Group. This group has been positive and well received by the staff, providing a platform for staff to support and implement change in the hospital. Some simple measures to improve the working environment have already been implemented such as rearranging the staff dining room to make it a more stafffriendly space. A number of refurbishment and replacement initiatives have been undertaken within the last 12 months with a continued facilities action plan to address areas such as some remaining patient bedrooms and the outpatient consulting rooms, which includes replacement sinks. The Hospital back-up generator was replaced last year and investment continues in purchasing and updating of theatre equipment. Replacement mattresses were bought for the ward following an annual external audit of both the beds and the mattresses Participation in clinical audit During 2015/2016 two national clinical audits covered NHS services that North Downs Hospital provides. North Downs Hospital participated in 100% applicable national clinical audits, submission rates as below: Indicator Percentage submitted Hip, knee and ankle replacements, National Joint 100% Registry (NJR) Elective Surgery, National PROMS Programme) Hernia ** (sample size too small) Hips 72.4% Knees 78.9% Page 18 of 41

19 The reports of these two national clinical audits were reviewed by the hospital management team during the year and we intend to continue to take the following actions to improve the quality of healthcare provided: Reports are reviewed by the local Clinical Governance Committee and Clinical Heads of Department meetings Comparative data is reviewed and shared with Consultants and by the Medical Advisory Committee. Please note that we are not eligible to participate in the majority audits which may be appropriate due to low patient numbers. North Downs was not eligible to participate in any national confidential enquires during 2015/2016. Communication in relation to reports from the organisation is circulated within North Downs. Local Audits In response to the Francis report on the Mid Staffs NHS Foundation Trust s Public Enquiry, North Downs is committed to ensuring that we offer safe, consistent, evidence-based care. We participate in the Ramsay Corporate Audit Programme (see Appendix 2), which is a robust schedule agreed by the corporate Clinical Governance Committee to allow greater opportunity for benchmarking. These audit results are evaluated at the relevant forums, e.g. Infection Control Committee Meetings, Clinical Governance Committee meetings, Medical Advisory Committee meetings, Clinical Heads of Department meetings and also at departmental meetings where findings can be discussed and action plans formatted. It is anticipated that with the appointment of a Quality Improvement Lead in the latter part of 2015, more robust action plans will be pulled together with regular review Participation in Research There were no patients during 2015/2016 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 North Downs Hospital s income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between North Downs Hospital and any person or body they entered into a contract, agreement or arrangement with for the Page 19 of 41

20 provision of NHS services, through the Commissioning for Quality and Innovation payment framework. The two proposed CQUINs for 2016/17 are the diabetic pre-operative fasting pathway and an adapted version of the Medicines Safety Thermometer. Both of these quality initiatives aim to improve the patient s journey whilst also preventing harm. These CQUINs will also benefit the staff by way of continuing professional development and empower them to educate patients Statements from the Care Quality Commission (CQC) North Downs Hospital is required to register with the Care Quality Commission and its current registration status on 31 st March is registered without conditions. The Care Quality Commission has not taken any enforcement action against North Downs Hospital during 2015/2016 North Downs Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. North Downs Hospital recent Care Quality Commission inspection report is due to be published in July The Hospital was last inspected in May 2016 where we were assessed in the Core Services of Surgery and Outpatients and Diagnostics Statement on Data Quality NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2014/15 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: The patient s valid NHS number: 99.96% for admitted patient care; 99.96% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). Page 20 of 41

21 Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2015/16 was 85% and was graded green (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: Clinical coding error rate The table below shows the percentage of coding accuracy following our internal audit of a random sample of patients post discharge. This audit is carried out by Ramsay s lead clinical coder and follows all the national guidelines. Ramsay Health Care Information Governance Req 505 Attainment Levels Achieved 2015/16 Internal Audit Hospital Site North Downs Audit Date Next Audit Date Primary Diagnosis Secondary Diagnosis Primary Procedure Secondary Procedure Jan % 95.0% 100% 96.4% Page 21 of 41

22 2.2.7 Stakeholders views on 2015/16 Quality Account Lead Commissioner Statement for Inclusion in Quality Account North Downs Hospital Ramsay Health Care Quality Account 2015/16 Statement from East Surrey CCG East Surrey Clinical Commissioning Group welcomes the opportunity to comment on North Downs Hospital Ramsay Health Care Quality Account 2015/16. The version of the quality accounts we reviewed did not appear to be aligned to 2015/16 consistently and we therefore advise Ramsay North Downs to review the accuracy and ensure current information reported aligns with the reporting period 2015/16. We congratulate the Provider on its achievements, particularly progress made with identifying Dementia Champions across all departments and supporting people with dementia or those requiring memory support. Also their excellent achievements in infection control with zero cases of MRSA over a 4 year period and zero Clostridium Difficile for the year 2015/2016. The CCG would have liked the quality account to have gone further in outlining specific areas which the provider is seeking to progress. For example, the version we reviewed had not yet included details of those services identified for improvement by the provider, such as ophthalmology and ambulatory care. We would ideally like to see greater use of comparative data to demonstrate the annual improvements that have been made, and to quantify the expected improvements in terms of measurable outcomes. The quality account report has opportunity to use a more patient friendly presentation, with explanation of abbreviations and professional terminology for greater clarity. The CCG would like to see in next year s report a summary of key themes around learning from improvements made and how these have been used to improve the patient experience. The CCG is pleased with the commitment to improving the patient experience and the support for staff. As Commissioners we are committed to continued collaborative working to assist the provider in the delivery of any actions identified following the publication of the CQC report which is due in July Page 22 of 41

23 Part 3: Review of quality performance 2015/ Statements of quality delivery Review of quality performance 1st April st March 2016 Statement from Vivienne Heckford 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 2015 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. Page 23 of 41

24 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 Page 24 of 41

25 NICE / National Commissioning Board guidance Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by the NHS Commissioning Board Special Health Authority. Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that are applicable to our business and thereafter monitoring their implementation. 3.2 The Core Quality Account Indicators North Downs Hospital considers that this data is as described for the following reasons: the services commissioned are planned surgical procedures and as such remain low risk. We have an extensive and effective pre-operative screening process ensuring that patient co-morbidities can be managed. During the last year we have broadened the process to incorporate a stage 1 pre-operative assessment at the patient s first initial clinic visit to highlight any potential clinical issues in a timely manner, which may impact on their suitability for surgery. This can then be addressed promptly either by anaesthetic assessment, onward referral or GP involvement. Ramsay have adopted the NEWS (National Early Warning Scoring System) allowing us to quickly identify patients who may have deteriorated post-operatively to limit any negative outcomes. Our robust clinical governance framework allows us to learn and improve. Mortality: Mortality: Period Best Worst Average Period North Downs Oct 13-Sep 14 RKE RPA 1.20 Eng /14 NVC11 0 Oct 14-Sep 15 RJ RVW 1.18 Eng /15 NVC11 0 There have been no deaths at North Downs during the last year. Patient Reported Outcome Measures (PROM s) PROM s are a series of questions that patients are asked in order to gauge their opinion on their current state of health and quality of life. Page 25 of 41

26 PROMS : Hernia Period Best Worst Average Period North Downs Apr14 - Mar15 Apr15 - Sep15 RD3 RJL R1H Eng RR Eng Apr14 - Mar15 Apr15 - Sep15 NVC1 1 NVC * PROMS : Veins Period Best Worst Average Period North Downs Apr14 - Mar15 Apr15 - Sep15 R1K 5.59 RTE Eng RK RM Eng Apr14 - Mar15 Apr15 - Sep15 NVC1 1 NVC1 1 * PROMS : Hips Period Best Worst Average Period North Downs Apr14 - Mar15 Apr15 - Sep15 NTE02 NVC RQX Eng RJL Eng Apr14 - Mar15 Apr15 - Sep 15 NVC1 1 NVC * PROMS : Knees Period Best Worst Average Period North Downs Apr14 - Mar15 Apr15 - Sep15 NT438 RVV RE9 RK Eng Eng Apr13 - Mar14 Apr15 - Sep15 NVC1 1 NVC * North Downs considers that this data is as described for the following reasons: The sample sizes for April September 2015 were not sufficient to obtain a score. We have changed our processes whereby we explain the importance of benchmarking and outcomes at our Joint School to encourage patients to complete both the pre- and postsurgery questionnaires. Provisional PROMs full data release report provides data from April 15 Dec 15 as it is published 6 months in arrears, which would give an incomplete picture and low volume responses. To give a complete years PROMs data for the purpose of our Quality Account, the reporting year used is The data has been taken from the provisional PROMs full data release report which provides data for the whole year from Mar 14 Apr 15. Hospital Readmissions Page 26 of 41

27 Monitoring rates of readmissions to hospital is another valuable measure of clinical effectiveness and outcomes. Any emerging trend identified with a specific surgical operation or team may identify contributory factors to be addressed. The table below shows the data set reviewing patients who were readmitted to hospital within 28 days of being discharged. The latest data sets available from SUS have been reported on for this Quality Account. Readmissions : Period Best Worst Average Period North Downs 2010/ /1 2 Multiple Multiple P Eng NL Eng / /1 2 NVC NVC North Downs considers that this data is as described for the following reasons: As evidenced in the template readmission rates are below the national average. Readmissions to North Downs are usually directly attributable to post-surgery symptoms such as urinary retention. We actively encourage patients to contact the hospital and will always ask them to come in for assessment by the RMO and are committed to helping them recover. All our patients are provided with written discharge advice on both their procedure and on any medication that they take home. North Downs aims to improve this rate further by investigating the root cause of readmissions and identifying any trends which can then be addressed. Venous Thromboembolism (VTE) The VTE assessment domain reviews data to see if patients are being treated and cared for in a safe environment and are being protected from avoidable harm. The data looks at all patients who have had an adequate risk assessment prior to admission in relation to the prevention of post-operative VTE events. VTE Assessment: Period Best Worst Average Period North Downs 15/16 Q2 15/16 Q3 Several 100% RWA 75.0% Eng 95.9% Several 100% RWW 61.5% Eng 95.6% 15/16 Q2 15/16 Q3 NVC % NVC % Page 27 of 41

28 Responsiveness to Personal Needs Patients and the public justifiably expect public services which respond to their needs and by monitoring patients experiences and improving patient satisfaction levels this will naturally result in positive service delivery improvements. This composite measure is made up of the five following survey questions: Were you involved as much as you wanted to be in decisions about your care and treatment? Did you find someone on the hospital staff to talk to about your worries and fears? Were you given enough privacy when discussing your condition or treatment? Did a member of staff tell you about medication side effects to watch for when you went home? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? This data set looks at the positive experiences of care provided by the hospital. The data has been extracted from the Care Quality Commission inpatient survey. The latest data release from the CQC has been reported. Responsiveness: Period Best Worst Average Period North Downs to personal 2012/13 RPC 88.2 RJ Eng /14 NVC needs 2013/14 RPY 87.0 RJ Eng /15 NVC There is no data available to North Downs Hospital or independent sector hospitals by the Health and Social Care Information Centre with regard to the hospitals responsiveness to the personal needs of it s patients during the reporting period 2015/16 North Downs considers that the data in the graph below reflects the fact that our patients tell us on the whole, we provide a service that is more responsive to their needs we compared to the national average for all providers in England. The most up to date data available is from 2013/14 The above table demonstrates that North Downs score is significantly higher than the national average (93.2% v 76.9%). This figure is reinforced by the very positive feedback that we receive, and where patients express a concern or have a complaint, these are acted upon in a prompt manner. Our figure also shows an improvement on the previous year. C-Difficile Infection Clostridium difficile infection (CDI) remains an unpleasant, and potentially severe or fatal infection that occurs mainly in elderly and other vulnerable patient groups especially those who have been exposed to antibiotic treatment. Page 28 of 41

29 C. Diff rate: per 100,000 bed days Period Best Worst Average Period North Downs 2013/14 Several 0 RMP 32.5 Eng /13 NVC /15 Several 0 RPY 62.2 Eng /14 NVC North Downs Hospital considers that this data is as described for the following reasons: The higher than the national average figure accounted for one isolated case in late This was a long-stay patient who contracted the infection as a result of prolonged antibiotic treatment. There have been no other C-Diff cases since then. North Downs aims to continue to maintain low infection rates by: North Downs Hospital has a local IPC Committee which is chaired by a Consultant Microbiologist and has representatives from all areas of the hospital. The committee meets quarterly to discuss any infections and identify any trends whilst also overseeing the implementation of corporate policies, national guidance and to review clinical audit and practice. All staff complete mandatory training in infection prevention and control on induction and on an annual basis which includes Hand Hygiene. Completion of corporate clinical audits, incident reporting, identifying trends and further training needs analysis. Information sharing at clinical governance level locally, corporately and with our commissioners. North Downs Hospital has adopted Anti-Microbial Stewardship to monitor best practice in relation to antibiotic prescribing. Patient Safety Incidents The Francis Report (2013) emphasised the need to put patients first at all times, and that they must be protected from avoidable harm. In addition to this the Berwick report (2013) recommended 4 guiding principles for improving patient safety, including; placing the quality and safety of patient care above all other aims for the NHS,; engaging, empowering, and listening to patients and carers throughout their journey at all times. Incident reporting supports clinicians to learn about why patient safety events occur within their own organisation, and look at ways in which they can improve the service to keep patients safe from avoidable harm. SUIs: Period Best Worst Average Period North Downs (Severity 1 Apr 14 - Sep Apr 14 - Several 0 RP Eng 0.15 only) 14 Sep 14 NVC Oct 14 - Mar Oct 14 - RD RJC 1.53 Eng Mar 15 NVC Page 29 of 41

30 Acute Non-Specialist Data From NRLS, England Average based on these sites only Figures are severe/death patient safety incidents per 1000 admissions (13/14) or per 1000 bed days(apr-sep14) North Downs considers that this data is as described for the following reasons: North Downs utilises the Riskman system to report all patient incidents in real time. All incidents are reviewed by the General Manager and an investigation process, root cause analysis and action plan are implemented where appropriate. The Corporate Risk Management Team is automatically alerted to incidents whereby they can be reviewed and any trends identified. As can be seen from the table there have been no serious incidents during the reporting period. However any such incidents would be reported to the CQC and the commissioners. North Downs embraces a no blame culture and encourages staff to report any incidents or near misses, however minor. Our aim is to: Continue to promote the importance of accurate reporting of all incidents Train staff on the Riskman reporting system Ensure that all incidents are discussed and analysed at the appropriate forums, e.g. Clinical Governance, Risk Management and that mechanisms are in place for learning points and outcomes to be shared with staff. Ramsay Health Care has an open culture whereby any serious events are shared within the group in order that we may review our own practices and therefore improve patient care and safety. Friends and Family Test F&F Test: Period Best Worst Average Period North Downs Jan-15 Several 100% RCUEF 72.7% Eng 95.7% Jan-16 NVC % Feb- 16 Several 100% RCUEF 74.2% Eng 95.7% Feb- 16 NVC % North Downs considers that this data is as described for the following reasons: Patient feedback is very important to us and as can be seen from the above scores North Downs is above the national average. We have a very caring team of professionals who are able to provide individualised care for our patients. This is mirrored in the accompanying comments on the survey which are disseminated on a monthly basis to the staff. North Downs intends to maintain these high standards by continuing to encourage service users to complete the survey; whilst also using the information to review standards and instigate action plans within the appropriate forums. Page 30 of 41

31 Infection Rates (percentage of Admissiosns) 3.3 Patient Safety We are a progressive hospital, and focussed on stretching our performance every year 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 Infection Prevention and Control (IPC) Infection Rates / / /16 North Downs Hospital North Downs continues to have a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in over 4 years. We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to reduce any incidents year on year. Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored with extensive root cause analysis for these. Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by the corporate IPC Committee and group policies are 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 with attendance Page 31 of 41

32 locally also at the Surrey IPCC meetings. Programmes and activities within our hospital include Local IPC meetings held on a quarterly basis which are led by Dr Bruce Stewart, Consultant Microbiologist from East Surrey Hospital. All infections are reviewed on an individual basis to identify any trends or changes to practise that may be required. All staff undertake annual mandatory training for Infection Prevention and Control which includes face to face sessions on Hand Hygiene. A comprehensive Infection Control Audit Programme has been maintained throughout 2016/2016. Audits undertaken during 2014/2015 achieved the following scores: Audit % Compliance Hand Hygiene 99 Environment Cleanliness 94 Surgical Site Infection 99 Peripheral Venous Catheter Care Bundle 96 Urinary Catheter Care Bundle Cleanliness and Hospital Hygiene Assessments of safe healthcare environments also include Patient- Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at North Downs Hospital, providing us with a patient s eye view of the buildings, facilities and food that 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. Site Cleanliness Food Organisational Food North Downs Ward Food Privacy, Dignity & Wellbeing Condition, Appearance & Maintenance Dementia 99% 91% 89% 97% 85% 85% 72% Environmental Audit We continue to complete the environmental audit quarterly; the aim of this audit is to highlight risks so that preventative steps can be taken to ensure a safe environment for all staff and patients. The objectives are: 1. To identify users and user groups 2. To advise on infection control issues arising as a result of the audit Page 32 of 41

33 3. To acknowledge where improvements are required The audit consists of an inspection of the hospital s clinical areas and includes the general environment, clinical equipment, decontamination, clinical practices, sharps handling, waste disposal and hand washing. We have completed 4 audits during this period of reporting - results as follows: Environmental Audit % Compliance Score May % August % November % February % We continue to focus on delivering a high standard of cleanliness and ensure that staff are informed and updated at our mandatory training study days as well as discussing the points raised at our bi-monthly Risk Management, Health and Safety Committee meetings. We have recently increased our resources in the housekeeping department in response to audit results which demonstrated that there was a need for greater input in this area Safety in the workplace Safety hazards in hospitals are diverse, ranging from the risk of a slip, trip or fall to incidents around sharps and needles. As a result, ensuring all staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness naturally extends to safeguarding patient safety. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine/device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. All relevant CAS alerts which require action are reviewed through Risk, Clinical Governance and Medical Advisory meetings. North Downs have allocated nurses on site who are linked to the Ramsay Wellbeing programme. This ensures that the needs of staff are met locally and facilitates close monitoring and robust reporting. All new starters complete a pre-placement occupational health questionnaire prior to appointment. Any occupational health issues during employment are managed via the Riskman reporting system. All staff at North Downs complete mandatory training in Health and Safety, Risk Management, Manual Handling and Fire Safety. Page 33 of 41

34 Retrnn to Theatre (Percentage of Admissiosns) 3.4 Clinical Effectiveness North Downs 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. 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. 0.3 Return to Theatre Score / / /16 North Downs Hospital As can be seen in the above graph our return to theatre remains very small in relation to the total number of admissions and represents 0.2% of the total number of admissions. Each individual event is reviewed in detail by the local Clinical Governance Committee to determine any actions required in order to reduce the risk of further returns; however there is no trend identified. Page 34 of 41

35 Readmission to hospital Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness. As with return to theatre, any emerging trend with specific surgical operation or surgical team in common may identify contributory factors to be addressed. Ramsay rates of readmission remain very low and this, in part, is due to sound clinical practice ensuring patients are not discharged home too early after treatment and are independently mobile, and not in severe pain Readmissions 13/14 14/15 15/16 North Downs Hospital As can be seen in the above graph the number of patients who required readmission has increased to 14 patients over the last year. We aim to ensure that any patient who has complications post discharge is only re-admitted if this is essential. Where in previous years patients may have been readmitted to the Trust for care/treatment we have aimed to bring patients back to North Downs when possible. There is no trend of re-admissions. Each event is reviewed in detail by the local Clinical Governance Committee. Transfer to External Hospital Transfer can be defined as the purposeful planned movement of patients from one health service to another. The main reason that a patient would transfer from North Downs to an acute hospital would be the requirement for advanced clinical support. The number has increased very slightly on last year, and whilst we have robust tools in place to recognise and manage the deteriorating patient, it is acknowledged that some transfers cannot be prevented, such as those requiring a higher level of care and/or specialist intervention. Page 35 of 41

36 0.50% Transfers 0.40% 0.30% 0.20% 0.10% 0.00% 13/14 14/15 15/16 North Downs Hospital 3.5 Patient experience 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 fed back to the relevant staff using direct feedback. Staff involved in a patient complaint are asked to provide written reflective accounts to help them to understand things from the patient s perspective. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care. Patient experiences are fed back via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy. Feedback regarding the patient s experience is encouraged in various ways via: Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48 hours Verbal feedback to Ramsay staff - including Consultants, QILs/General Managers whilst visiting patients and Provider/CQC visit feedback. Yearly CQC patient surveys Page 36 of 41

37 Satisfaction Scores Written feedback via letters/ s Patient focus groups PROMs surveys Care pathways patients 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, Qa Research. This is to ensure that results are managed completely independently of the hospital so that we receive a true reflection of our patients views. Every patient (both inpatient and outpatient) is asked for their consent to receive an electronic survey or phone call after they leave hospital. The results from the questions asked are used to influence the way in which the hospital seeks to improve it s services. Any free text comments made by patients on their survey are sent as hot alerts to the General Manager within 48 hours of receiving them so that a response can be made to the patient as soon as possible. 100 Satisfaction Scores NHS/Private Patients / /16 North Downs Hospital Results are produced quarterly (the data is shown as an overall figure but also separately for NHS and private patients). Patient satisfaction scores for overall quality show the majority of patients feel they receive excellent quality of care and service in North Downs Hospital. To record a satisfaction index over 90%, a very high proportion of our patients have scored 9 or 10 out of 10 for their satisfaction with all the requirements. Page 37 of 41

38 North Downs Hospital Case Study Nurse Led Urology Clinics Over the last 12 months we have further developed our Nurse Led Urology services. Our Urology Specialist Nurse is able to receive referrals from several Consultant Urologists and commence treatment for painful bladder syndrome; chemotherapy for bladder cancer; changing of supra-pubic catheters; teaching intermittent self-catheterisation for patients who are in retention or who have urethral strictures. She also has established good relationships with community services for ongoing care and supplies of equipment. She is able to offer advice and support to this group of patients who have specialist needs, including patients from our sister hospital at Ashtead. As such her caseload has grown over recent months. A patient who had suffered chronic urinary retention for many years was referred to our specialist nurse. This patient had had an indwelling catheter for a great length of time and this impacted on their lifestyle to an extent which had become intolerable. The nurse specialist spent a great deal of time over a period of weeks teaching the patient how to self-catheterise, whilst also offering emotional support and counselling in this sensitive subject. The patient was subsequently able to be free of a permanent catheter and gained a new lease of life. The feedback from this group of patients is extremely positive they feel that they have a point of contact with an approachable and understanding professional who offers flexibility with her appointment times and is sensitive to their requirements. Page 38 of 41

39 Appendix 1 Clinical Audit Programme 2015/16. Each arrow links to the audit to be completed each month Page 39 of 41