Rivers Hospital. Quality Account 2014/15

Transcription

1 Rivers Hospital Quality Account 2014/15

2

3 Contents Welcome to Ramsay Health Care UK 4 Introduction to our Quality Account 5 PART Statement from the General Manager Hospital accountability statement Welcome to the Rivers 8 PART Priorities for Improvement Review of Clinical Priorities 2014/15 (looking back) Clinical Priorities for 2015/16 (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 2014/15 Quality Accounts 22 PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 Statements of Quality delivery The Core Quality Account indicators Patient Safety Clinical Effectiveness Patient Experience 38 Appendix 1 Clinical Audits 14

4 Welcome to Ramsay Health Care UK Rivers 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 provision of high quality patient care is and will always be the highest priority of Ramsay Health Care UK. Of course our team of clinical staff and consultants are very much at the forefront of achieving this; but there is also very much an organisation wide commitment to ensure that we continue to improve our outcomes every day, week, month and year. Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot be the responsibility of just a few, it takes all of us to be responsible and accountable for our performance in the various roles we all play. Having an organisational culture that puts the patient at the centre of everything we do is key to ensuring we enable everyone to perform at their peak to attain great outcomes. Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends, we will continue to strive to get ever better. I am very proud of our long standing and major provider of healthcare services across the world and of our Ramsay very strong track record as a safe and responsible healthcare provider. It gives us pleasure to share our results with you. Mark Page Chief Executive officer Ramsay Health Care UK Page 4 of 42

5 Introduction to our Quality Account This Quality Account is Rivers 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 5 of 42

6 Part Statement on quality from the General Manager Rivers Hospital has a tradition of working closely with consultants and patients to ensure the best quality healthcare is consistently being delivered. Our Hospital staff are fully trained in the latest procedures and thus maintain all areas to the highest standards. Working within the Department of Health guidelines we focus on patient safety and cleanliness to minimise infection. Care Quality Commission (CQC) Inspection outcomes reflect the high quality at Rivers and therefore support excellent reputation. As General Manager of Rivers Hospital, I take great pride in the service we offer our patients and relatives; this is only achieved through a cohesive team effort and approach. Rivers Hospital Vision Statement is to be a leading provider of health care services by delivering high quality outcomes for patients and ensuring long term profitability. 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. 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 organisation, but most importantly the views of patients and their families which have been sought though questionnaire survey, comment sheets and focus groups. Furthermore, you are invited to feedback on this document by sending any comments in writing to me at the Hospital. Andy Haysman General Manager Rivers Hospital Page 6 of 42

7 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. Andy Haysman General Manager Rivers Hospital Ramsay Health Care UK Page 7 of 42

8 Welcome to Rivers Hospital The Hospital is located in Sawbridgeworth on the Essex/Hertfordshire border in beautiful countryside. The Hospital opened in 1992 and is equipped with the latest medical facilities for diagnosis and treatment, and has very high quality clinical standards. We provide fast, convenient, effective and high quality treatment for patients of all ages (children over the age of 3 years as inpatients), whether medically insured, self-pay, or NHS funded. We have 57 beds, 53 of which are in individual rooms, 2 of our rooms are double occupancy.. This not only maintains the privacy and dignity of patients, it also assists in maintaining infection control isolation. All our patient rooms are en-suite enhancing patient comfort. Our wards are staffed with 75:25 qualified to non-qualified nurse ratio. Patient to nurse ratio does not exceed 7:1. This year we have treated 2,606 in-patients and 7,584 day cases on the ward. Alongside our RGNs we have a number of specialist nurses, including chemotherapy nurses, plastics, urology and orthopaedic nurses. The ward also employs 2 paediatric nurses. The Hospital has 2 dedicated HDU beds for patients requiring higher level of support. There are four fully equipped theatres with ultra clean air technology and separate recovery annex. The theatre team is highly skilled and adheres to the 5 steps to safer Surgery. There is a dedicated 9 bay day Surgery suite. This is JAG accredited and used mainly for endoscopy, of which we have performed over 2,000 procedures in the past year. The unit is also utilised for pain management and minor urology procedures. The outpatient department has 13 consulting rooms, and 3 treatment rooms which are used for minor operations. We have a pre-admission unit which enables us to assess the needs of our patients prior to admission. These departments are open until 8pm to allow patients access to care and treatment at a time to suit. There is modern equipped physiotherapy department and gym. Patients can access specialist orthopaedic physiotherapy, shockwave therapy along with sports massage. We have a state of the art imaging department with x-ray, ultrasound, CT & MRI scanning facilities, Digital Mammography and DEXA scanning (Osteoporosis). Patients may self-refer for Cosmetic Surgery consultation, and for Physiotherapy services. All our services are Consultant led, by over 200 Consultants. A rigorous vetting procedure ensures that only suitably qualified and experienced surgeons are granted practicing privileges at the Hospital. The service is supported by the presence of the Resident Medical Officer (RMO) 24 hours a day. The staff at Rivers Hospital are professional and friendly, and deliver high levels of customer service evidenced by the positive feedback we receive. We currently employ 81 RNs/ODPs,41 HCAs, 14 Physiotherapists, 2 Physiotherapy Technicians, 11 Radiographers, 3 Pharmacists, 2 Pharmacy Technicians, 73 Administration Staff and 48 support service staff. Rivers Hospital Bank provides extra support and flexibility to the service when required. Page 8 of 42

9 The Hospital invests in all staff, ensuring they have the relevant training and skills to fulfil their role. The Hospital also has access to online training, webinars and the Ramsay Academy. This provides strategic and consistent training provision across the Ramsay Company. The Hospital is regulated and audited by the Care Quality Commission. Throughout the past year we have developed close relationships with the Local Clinical Commissioning Groups (CCG s) ensuring our services meet local needs. We maintain close links with the local Hospitals namely Princess Alexandra NHS Trust (Harlow) and East and North Herts NHS Trust (Welwyn Garden City and Stevenage). Rivers employs a GP liaison officer and holds GP events to ensure local GPs are well informed about the services offered at the Hospital. By investing in advanced medical technology, Rivers is able to offer a large range of elective surgical, non-surgical and outpatient treatments across the following specialties: Allergy Clinic, Breast /Reconstructive Surgery, Cardiology (Cardio-thoracic Surgery at Orwell Suite), Colo-rectal Surgery, Cosmetic Surgery, Dermatology, Diabetes/Endocrinology, Diagnostic Services, Dietician, Ear, Nose and Throat, Endoscopy, Fertility services, Gastro-enterology, General Medicine, General Surgery, Gynaecology, Haematology, Health Screening, Laparoscopic Surgery, Neurology, Neuro-Radiology, Oncology, Ophthalmology, Oral and Maxillo-Facial Surgery, Orthopaedic Surgery, Paediatric Services, Pain Medicine, Pharmacy, Physiotherapy, Plastic Surgery, Private GP & Practice Nurse service, Psychiatry, Psychotherapy, Rheumatology, Spinal Surgery, Urology including Brachytherapy, Vascular, Weight-loss Clinics, Bariatric Surgery. The Hospital attracts referrals from sister Hospitals within Ramsay Eastern region as a specialised centre for services such as Brachytherapy (Prostate Cancer), Chemotherapy services (Cancer), DEXA scanning (Osteoporosis), Phototherapy (Skin conditions), and on site CT scanning (Diagnostic Imaging). We also have on site MRI and Digital Mammography. Rivers acts as a satellite for other centres to offer services through a hub & spoke system. These include Fertility services (Bridge Fertility Centre) and Cardio-thoracic Surgery (Ramsay Orwell Suite). Rivers Hospital is delighted to be recognised as Private Healthcare UK s Patients Choice for The best clinic in the UK. Rivers Hospital was one of only six to achieved outstanding patient satisfaction ratings from the 20,000 Hospitals and clinics listed on Private Healthcare UK. Rivers Hospital has been awarded 5 out of 5 stars for hygiene by the East Herts Council for 6 years in a row. Rivers received the highest award for excellent hygiene conditions, very high standard of compliance with food hygiene legislation and very high confidence in the management Earlier this year Ramsay Sterile Services East was audited and awarded third party certification for ISO 13485:2012, ISO 9001:2008 and 93/42/EEC Annex V limited to sterility. The unit is now able to register with Medicines and Healthcare products Regulatory Agency. (MHRA) and is permitted to provide products to other organisations (anywhere within Europe). The audit was performed by Intertek, which is a Notified Body (reg no. 0473) for the Medical Devices Directive. Rivers has won a Green Apple Environment Award in the national campaign to find Britain s greenest companies, councils and communities. The Green Apple Awards began in 1994 and have become established as the country s major recognition for environmental endeavour among companies, councils, communities and countries. Page 9 of 42

10 Part Priorities for Improvement for 2015/2016 Plan for 2015/16 On an annual cycle, Rivers 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 Hospital s 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) Quality Improvement Lead We have recruited the Quality Improvement lead. This has increased the Hospitals analysis of patient feedback and submission rates. We have now attained 47% total feedback submission for our inpatients over the year. Surgical Site Infections have been closely investigated and our very low rates of infection maintained. Patient-Reported Outcome Measures (PROMs) for both hips and knees have been scrutinised and, again, Rivers are above the national benchmark for improvement. The external reporting has also increased, allowing the Hospital to evidence the high level of quality to the CCG. We have succeeded in 100% of the National and Local Quality Improvement goals (CQUINs) set by the CCG. These included extending the Surgical Site Infection monitoring to further procedures, and screening over 90% of eligible patients for Dementia. Slips, trips and falls recorded/reported during 2013/14 were 21; in 2014/2015 there was a total of 14 falls reported throughout the Hospital which shows a marked improvement. All staff are aware of the importance of reporting all incidents including slips, trips and falls on the incident reporting system. Staff continue to minimise the risk of slips, trips and falls through the use of risk assessments. Page 10 of 42

11 Incident Reporting The quality of reporting of incidents on the Riskman system has improved significantly over the year. The figures show an increase in incident reporting, reflecting a raised awareness and improved reporting of actual incidents onto our Riskman reporting system. Staff have been educated in the use of the system and are aware of the types of incidents to report. This has given the Hospital an elevated understanding of the types, severity and numbers of harms experienced. Incidents are reviewed in a timely manner and lessons learnt are shared. Root Cause Analysis (RCA) is used to ensure that where problems arise, systems and practices are overhauled to reduce the chances of incidents recurring. 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. This has enabled the Hospital to accurately assess how incidents vary across the organisation, and comparatives are made with other providers, this ensures we are travelling in a positive direction. We will continue to monitor incidents and review feedback in order to learn from lessons learned and instigate actions to prevent recurrence. Rivers has a no-blame approach to ensure positive encouragement is given to incident and near-miss reporting. Patient Feedback Rivers has continued to monitor improvement through patient feedback. The Hospital asks all patients to complete the We Value Your Opinion survey to enable us to collate patient opinion and act immediately upon any concerns. We also have children s questionnaires, one side for parents and one side for the child to evaluate care and facilities. Rivers has had excellent, positive feedback following the introduction of the friends and family test. The scores indicate that NHS day case and inpatients were extremely likely to recommend Rivers Hospital to friends and family with a score of 95% and 98% respectively. The following are some examples of how we have improved care within the Hospital as a direct result of the comments received from the We Value Your Opinion questionnaires: Patient comment: Staggered registration time to avoid sitting about waiting for your operation list would save stress worry. We did - this has now been implemented by the ward for cataract patients. When possible, patients are brought in later to avoid lengthy pre-op waiting times. We are finding ways to reduce this further by extending to other procedures. Patient comment: I found parking to be difficult when attending for outpatient appointments as the car park was very busy. We did -additional parking has been added to the site. The following are examples of the positive feedback we have received: Nurses are above and beyond and go the extra mile with all care Page 11 of 42

12 I was looked after wonderfully well, extremely happy with my nurse The staff are all very friendly and helped made visit very comfortable All staff extremely nice, explaining everything in full. Peaceful atmosphere excellent care, friendly atmosphere. Lovely surroundings! This all puts you at ease and less stress In addition to the written feedback we hold quarterly patient group meetings. Patients are invited to the Hospital to discuss recommendations and any changes, this attended by representative from all areas within the Hospital. The Rivers recognises that patient experience is the key measure of quality and a driver for improvement Rivers participated in the National PLACE (Patient-Led Assessments of the Care Environment) audit, this took place in April These assessments include rating of privacy and dignity, food and food service, access issues such as signage, bathroom / toilet environments and overall cleanliness. Patients make up at least 50% of the assessment team giving them a much stronger voice. The focus is on improvement, with Hospitals reporting publicly on how they plan to improve. Rivers scored 100% in cleanliness, ward food and wellbeing. In addition we have trained 90% of all staff in Customer service. This training enforces a raised awareness of patient perception and expectation; reminding staff of the importance of consistent excellence in customer care. The outcome is a heightened patient satisfaction score. Development of facilities We have commenced the development of our facilities. The additional car parking has been completed which in turn has increased patient satisfaction. The upgrading of the outpatient consulting rooms and patient bedrooms are well underway. Provisional dates for the fifth theatre and related works to be completed is May Clinical Priorities for 2015/16 (looking forward) Improving safety As demonstrated in this report, the Hospital aims to provide safety to all patients and staff. As a direct response to the publication of the following reviews and reports; Francis report on Mid Staffordshire (Francis 2013) Keogh review into the quality of care and treatment provided in 14 Hospital trusts in England (Keogh 2013) Cavendish review, an independent enquiry into healthcare assistants and support workers in the NHS and social care setting (Cavendish 2013) Berwick report on improving the safety of patients in England (Berwick 2013). The need for guidelines on safe staffing, including nursing staff, was also highlighted in the recent policy documents and responses: How to ensure the right people, with the right skills, are in the right place at the right time. A guide to nursing, midwifery and care staffing capacity and capability (National Quality Board 2013). Hard truths. The journey to putting patients first (Department of Health 2013). NICE have developed evidence- Page 12 of 42

13 based guidelines on safe staffing, with a particular focus on nursing staff. (Safe staffing for nursing in adult inpatient wards in acute Hospitals -Safe staffing guideline 1 (NICE July 2014). Rivers will be looking into nursing red flags to closely monitor staffing levels in the ward area. Nursing red flags: Delay of more than 30 minutes in providing pain relief. Patient vital signs not assessed or recorded as outlined in the care plan. Delay or omission of regular checks on patients to ensure that their fundamental care needs are met as outlined in the care plan. Carrying out these checks is often referred to as 'intentional rounding' and covers aspects of care such as: - Pain: asking patients to describe their level of pain level using the local pain assessment tool. - Personal needs: such as scheduling patient visits to the toilet or bathroom to avoid risk of falls and providing hydration. - Placement: making sure that the items a patient needs are within easy reach. - Positioning: making sure that the patient is comfortable and the risk of pressure ulcers is assessed and minimised. A shortfall of more than 8 hours or 25% (whichever is reached first) of registered nurse time available compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift. If a shift requires 15 hours of registered nurse time, a red flag event would occur if 11 hours or less of registered nurse time is available for that shift (which is the loss of more than 25% of the required registered nurse time). Less than 2 registered nurses present on a ward during any shift. If a nursing red flag event occurs, it should prompt an immediate escalation response by the registered nurse in charge. An appropriate response may be to allocate additional nursing staff to the ward. Events that prompt an immediate response by the registered nurse in charge of the ward. The response may include allocating additional nursing staff to the ward or other appropriate responses. Both the red flags will be monitored and the responses taken. We also recognise that we need to work on our Safeguarding training. Plans are in place to ensure all relevant staff are trained to the appropriate levels as described by the recent intercollegiate document. Improving Responsiveness Working with the CCG s Rivers is planning to reduce the number of unnecessary outpatient appointments by 80%. This will involve analysis of the current position, and the careful selection of applicable encounters. We will then continue to monitor monthly and provide quarterly reports to the CCG. Ultimately this will expand the responsiveness of the service by reducing waiting times and eliminating any unnecessary visits for patients. Rivers continually strives to build upon and improve facilities for our customers and outside stakeholders. The Hospital is responding to the needs of the population by investing nearly 11 Million on developing the services. This includes a Cancer Centre, incorporating both radiotherapy and chemotherapy delivery. 12 day care beds, 2 additional consulting rooms, physiotherapy treatment Page 13 of 42

14 room, additional administration space, car parking and ancillary facilities. For the Cancer Centre we are targeting a December opening. Improving Care and effectiveness We intend to continue to monitor patient feedback in order to build upon the patient experience at Rivers Hospital. We pride ourselves as being the Hospital of choice for all our patients and fully intend to continue to provide a first class service. 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 with the aim to reduce patient complaints by 10%. The current rate is 89 complaints for the year, from a total of 96,710 attendances. 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 2014/15 Rivers provided the following NHS services: Carpel Tunnel and Trigger finger Cataract Colorectal Surgery Ear Nose and Throat Endoscopy (Lower and Upper) Gall Stones and Gall Bladder Surgery Gastroenterology General Surgery Gynaecology Hernia Repair Hip and Knee Arthroscopy Hip and Knee Clinics Ophthalmology including Laser Oral Maxillofacial Surgery Orthopaedics Pain Management Spine and Neck Clinic Page 14 of 42

15 Urology The Hospital has reviewed all the data available to them on the quality of care in all of these NHS services. Ramsay uses a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year. The scorecard is reviewed each quarter by the Hospitals senior managers together with Regional and Corporate Senior Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other Hospitals and identifying key areas for improvement. In the period for 2014/15, the indicators on the scorecard which affect patient safety and quality were: Human Resources Indicator HCA Hours as % of Total Nursing Agency Cost as % of Total Staff Cost Ward Hours PPD % Staff Turnover % Sickness % Lost Time Appraisal % Mandatory Training % Staff Satisfaction score Number of Significant Staff Injuries 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 Formal Complaints per 1000 HPD's Patient Satisfaction Score Significant Clinical Events per 1000 Admissions Readmission per 1000 Admissions Never Events 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: We have had no never events at the Rivers in the past year. Page 15 of 42

16 Quality Indicator Workplace Health & Safety Score Infection Control Audit Score Consultant Satisfaction Score Friends and Family Over the past year 46% of inpatients completed the friends and family feedback form. 486 patients said that they would be extremely likely to recommend friend and family, the remaining 11 stated they would be likely to recommend friend and family. Friends and Family score likely 2% extremely likely 98% Participation in clinical audit During 1 April 2014 to 31 st March 2015 Rivers participated in 100% of national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate in. The national clinical audits and national confidential enquiries that Rivers participated in, and for which data collection was completed during 1 April 2014 to 31 st March 2015, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Page 16 of 42

17 Elective Surgery (National PROMs Programme) Pre-operative Participation Rivers Participation Rate England Participation Rate Groin Hernia 44.5% 60.8% Hip Replacement 46.5% 87.1% Knee Replacement 48.3% 95.1% National Joint Registry Rivers NJR KPI Participation Rate Number tracing compliance 98% 90% Consent Rate 97% 90% This quarter (shown on the NJR report as Q1 2013/14) has seen Ramsay s overall consent rate maintain an excellent 97% and the NHS number tracing compliance remain at 98%. Both rates continue to put the Ramsay Group well above the NJR KPI of 90%. On examination of the data it can be seen that, although participation rates have increased since last year, work is required to increase the participation rate further. The increased rate can be attributed to the fact that the issue rate has increased to a very positive 100%. In addition to the above we also take part in the Health Protection Agency Surgical Site surveillance (see section 2.3.1) and the NHS Safety Thermometer. NHS Safety Thermometer We have submitted data for 100% of the identified patients. It was recognised that we needed more transparency between ourselves and other independent sector providers/the NHS in order to monitor and improve our services. Rivers caries out a VTE risk and falls assessment on all admitted surgical patients as per Ramsay Policy No CM001 and adheres to National Institute for Clinical Excellence (NICE) Guidance Compliance is audited through a robust corporate and local audit programme and results/action plans reviewed through Clinical Governance. Compliance results are benchmarked through the National Statistics at: The tables below highlight that 100% of our patients have been screened since April 2014 and our % of VTE is below that of the national average. Page 17 of 42

18 Surgical Site Surveillance Actual No of Completed % Submission operations forms TAH Spine THR TKR Rivers submit data to Public Health England to monitor the percentage of Surgical Site Infections. The submission rates for the SSI s have increased throughout the year. Local Audits In response to the Francis report on The Mid Staffordshire NHS Foundation Trust s Public Enquiry Rivers is committed to ensuring that we offer safe consistent practice and care by instigating regular audit practice. Page 18 of 42

19 The Hospital participates in the Ramsay Corporate Audit programme (the schedule can be found in appendix 2) the audit topic and schedule is set centrally by Ramsay Health Clinical Governance Committee to allow greater opportunity for benchmarking. The programme includes audits such as WHO safer Surgery and Hand Hygiene. Additionally, Rivers also carries out a number of internal clinical audits all of which are discussed and reviewed and actions are taken to improve the quality of healthcare provided. The completion of local audits ensures compliance is monitored to ensure continuity of care and safe effective practice. Rivers currently evaluates all audits and local audit practice by completing action plans if the scores of audits fall within 95% or less of the rating score. These action plans are reviewed and amended as required until achievement is met Participation in Research There were no patients recruited during 2013/14 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 Rivers income in from 1 April 2014 to 31 st March 2015 was conditional on achieving quality improvement and innovation goals agreed 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 (CQUIN). The CQUIN chosen for 2015/16 is 1.0 Outpatient follow up. This CQUIN looks to reduce the number of patients who are attending as an outpatient following Surgery, where their recovery would deem this an unnecessary appointment with limited clinical value to the patient. The CCG perceive these attendances as a poor use of NHS resources. In the United Kingdom, it has been common practice for patients to be offered an outpatient appointment with their specialist, after routine Surgery, commonly 6 8 weeks after discharge. The value of outpatient follow up has been questioned for many years and surgeons vary widely in their practice: some review all patients after common procedures, while others review none. The arguments for follow up include the need to monitor progress and to identify complications and recurrences and the need to reassure patients. However, postoperative complications and recurrences are most commonly detected by members of the primary care team. Furthermore, postoperative problems have often resolved by the time of the Hospital follow up appointment. Many patients would be confident in a system without routine Hospital review. Giving patients control over their aftercare and the ability to decide if they require a Consultant review. Page 19 of 42

20 2.2.5 Statements from the Care Quality Commission (CQC) Rivers is required to register with the Care Quality Commission and its current registration status on 31 st March is registered without conditions. Rivers was last inspected on the 4 th December The following 5 standards were inspected: Treating people with respect and involving them in their care Providing care, treatment and support that meets people's needs Caring for people safely and protecting them from harm Staffing Quality and suitability of management The CQC concluded that all of the inspected standards were fully met. Rivers is anticipating re-inspection from the CQC under the new inspection regime. Core services to be inspected include: Surgery, cosmetic Surgery, urgent care services, medical care, children and young people s care and outpatients. Each inspection seeks to answer five questions about services, these are: are they safe, caring, effective, well-led and responsive to people s needs? Data Quality Improving data quality and clinical coding can deliver clinically meaningful information that can be used to demonstrate quality, patient safety and act as an early warning system for poor or declining performance. This is particularly important following the events at Mid Staffordshire where the Francis Inquiry recommended that "All healthcare provider organisations should develop and publish real time information on the performance of their consultants and specialist teams in relation to mortality, morbidity, outcome and patient satisfaction, and on the performance of each team and their services against the fundamental standards." (Mid Staffordshire Inquiry Feb, 2013) On induction our staff are trained on how to obtain and input data correctly onto our electronic systems and also how to handle it confidentially. Staff are monitored on correct data capture via internal reports and data quality training is updated regularly throughout the Hospital. Ramsay Healthcare are implementing a new electronic patient record system this coming year. The new system EPR Maximus will be an improvement on the current system for the following reasons: It is a modern system with improved performance All information in one place Care pathways/electronic forms will be accessible Theatres functionality to maintain constancy across the site E-discharge, improving the current situation of hand written discharge letters Allows Ramsay to progress - e-prescribing and medicines administration Integration removing risk and improving quality To ensure we have seamless process of data collection from the EPR system to the billing system. Currently paper records are audited for both adult and paediatric records as part of the Ramsay Audit. Page 20 of 42

21 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: 99.97% 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). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2014/5 was 75% and was graded green (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: Clinical coding error rate Rivers employs a Clinical Coder who is responsible for all procedure coding. Internal clinical coding audits are performed on a regular basis. Rivers Hospital was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission. Page 21 of 42

22 2.2.7 Stakeholders views on 2014/15 Quality Account West Essex CCG as Lead Coordinating Commissioners have had the opportunity to review this document and at time of publishing and have not shared any feedback to be added. Page 22 of 42

23 Part 3: Review of quality performance 2014/ Statements of quality delivery Review of quality performance 1st April st March 2015 This publication marks the sixth 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 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. 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 Page 23 of 42

24 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. Page 24 of 42

25 3.2 The Core Quality Account indicators Mortality: Mortality: Period Best Worst Average Period Rivers Jan13-Dec13 RKE 0.62 RXL 1.18 Eng /14 NVC19 0 Apr13-Mar14 RKE 0.54 RBT 1.20 Eng /15 NVC SHMI Figures are not available for Independent Sector Hospitals. Inferred average mortality rate is 3.39% Prescribed Information The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to (a) the value and banding of the Summary Hospital-Level Mortality indicator ( SHMI ) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator. Related NHS Outcomes Framework Domain 1: Preventing people from dying prematurely 2: Enhancing quality of life for people with long-term conditions Rivers Hospital considers that this data is as described for the following reasons: In addition to providing elective surgical care and treatment, Rivers provides care and treatment for private patients with long term chronic medical conditions and end stage cancer under the care of Consultant Oncologists and Physicians. A proportion of these patients choose to stay at the Hospital for their end of life care. The table gives the number of deaths that have occurred at the Hospital in the last year, we have had no unexpected deaths during the reporting period. Our low rate of unexpected death is evidence of our surgical safety and commitment to preventing people dying prematurely. Rivers Hospital intends to maintain this extremely low level of mortality and so the quality of its services, by continuing to report all deaths on the Riskman reporting system to allow full incident investigation, root cause & gap analysis of care episodes. PROMs Patient-Reported Outcome Measure (PROM) is a series of questions that patients are asked in order to gauge their views on their own health. The purpose of PROMs is to get patients own assessment of their health and health-related quality of life PROMs questionnaires do not ask about patients satisfaction with or experience of health care services, or seek their opinions about how successful their treatment was. Annual datasets are typically finalised fifteen months after the end of the reporting period that they cover. The Oxford Scores focus on joint function and pain and include questions about patients mobility and factors such as ability to navigate stairs and use transport specifically affected by the hip or knee. The EQ-5D TM Score, is a standardised instrument for use as a Page 25 of 42

26 measure of health outcome and has a broader base than the Oxford Scores. Its questions relate to mobility, self-care, usual life activities, pain/discomfort and anxiety/depression. PROMS: Period Best Worst Average Period Rivers Hernia Apr13 - Mar14 NT NVC Eng Apr13 - Mar14 NVC Apr14 - Sep14 RXR Several Eng Apr14 - Sep14 NVC PROMS: Period Best Worst Average Period Rivers Hips Apr13 - Mar14 NT RQX Eng Apr13 - Mar14 NVC Apr14 - Sep14 RCB RJD Eng Apr14 - Sep 14 NVC19 * PROMS: Period Best Worst Average Period Rivers Knees Apr13 - Mar14 NT NV Eng Apr13 - Mar14 NVC Apr14 - Sep14 RWP RXF Eng Apr14 - Sep14 NVC19 * (* denotes insufficient data for publishing from the 2 questionnaires following case-mix adjustment by the NHS data centre.) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s Patient Reported Outcome Measures scores for (i) groin hernia Surgery, (ii) varicose vein Surgery, (iii) hip replacement Surgery, and (iv) knee replacement Surgery, during the reporting period. 3: Helping people to recover from episodes of ill health or following injury Rivers Hospital considers that this data is as described for the following reasons: Outlined in table above are the patient reported outcomes for Rivers. This is compared to the national best, worst and average scores from the UK. At present the Hips and Knee scores are not statistically viable as we have received 6 hip and 10 knee modelled records. There are two questionnaires: the preoperative survey, administered by staff in Hospitals; and the post-operative survey, sent to patients 3 months or 6 months after their operation, direct to their home address. This delay is needed both to allow sufficient recovery time after Surgery before post-operative questionnaires are completed and to maximise the number of post-operative questionnaires returned. A further six weeks (approximately) is necessary for data processing, analysis and production and checking of the annual publication. The figures for this report will change over the next months as further questionnaires are modelled. The data is validated and positively shows that Rivers are producing Adjusted Health gains higher that of England evidencing our commitment to enhancing the quality of life for our patients. Rivers Hospital has taken actions to improve the number of forms submitted and therefore increase the score, and so the quality of its services. Hospital Re-admissions Monitoring rates of readmission to Hospital is another valuable measure of clinical effectiveness & outcomes. As with return to theatre, any emerging trend identified with a specific surgical operation or surgical team may identify contributory factors to be addressed. Page 26 of 42

27 Readmissions: Period Best Worst Average Period Rivers 2010/11 Multiple 0.0 5P Eng /11 NVC /12 Multiple 0.0 5NL Eng /12 NVC The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged (i) 0 to 14; and (ii) 15 or over, Readmitted to a Hospital which forms part of the trust within 28 days of being discharged from a Hospital which forms part of the trust during the reporting period. 3: Helping people to recover from episodes of ill health or following injury Rivers Hospital considers that this data is as described for the following reasons; as evidenced in the template readmission rates are below the average national rate, in part, is due to sound clinical practice & governance ensuring patients are not discharged home too early after treatment, are independently mobile and that patients are fully informed of individual discharge information. We are committed to helping people recover from episodes of ill health or injury. Rivers Hospital intends to take the following actions to improve this rate, and so the quality of its services, by; Completion of Corporate audits, incident investigation, reporting, root cause and gap analysis. This will aid to monitor any trends in readmission to enable eradication. Responsiveness to the personal needs Patients and the public justifiably expect public services which are responsive to their needs and driven by them. Monitoring Patient experience and improving patient satisfaction leads to positive service improvements. This composite measure is made up of the following five 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? Responsiveness: Period Best Worst Average Period Rivers to personal 2012/13 RPC 88.2 RJ Eng /13 NVC needs 2013/14 RPY 87.0 RJ Eng /14 NVC The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s responsiveness 4: Ensuring that people have a positive experience of care Page 27 of 42

28 to the personal needs of its patients during the reporting period. Rivers Hospital considers that this data is as described for the following reasons the above table demonstrates that Rivers score is above that of England. We are receiving very positive feedback from the patients, when negative comments are received Rivers acts quickly to amend and respond to patients. Rivers are putting patients at the heart of everything, delivering timely access to services, treatment and care that is compassionate, dignified and respectful wherever it is provided. Rivers Hospital has taken the following actions to improve this score, and so the quality of its services, by Continuing to monitor and act upon Feedback from patients. Patient s experience is received through the following routes: Patient satisfaction surveys We value your opinion questionnaire leaflet Direct verbal feedback to Ramsay staff. Internal Ramsay audit /inspection processes. CQC inspection feedback. Written feedback via letters/ s/complaints Patient focus groups PROMs surveys Care pathways patients are encouraged to read and participate in their plan of care. Annual PLACE patient audit All staff attend customer care training Venous Thromboembolism (VTE) From 1 June 2010, the Department of Health (DH) required that VTE risk assessments take place for every patient, and that results are closely monitored in order to reduce the 25,000 preventable deaths that occur in UK Hospitals every year. The trigger for the VTE prevention pathway is the assessment of risk so that appropriate preventative treatment can be given in line with national clinical guidance and outcomes can be improved. This is the focal objective of the National VTE Prevention Programme and its delivery is supported by a number of measures that have been introduced over the last number of years. VTE Assessment: Period Best Worst Average Period Rivers 14/15 Q2 Several 100% RNL 86.4% Eng 96.2% 14/15 Q2 NVC % 14/15 Q3 Several 100% NT % Eng 96.0% 14/15 Q3 NVC % Page 28 of 42

29 The data made available to the National Health Service trust or NHS Foundation Trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to Hospital and who were risk assessed for Venous Thromboembolism during the reporting period. 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Rivers Hospital considers that this data is as described for the following reasons; over 98% of our patients have been screened with the VTE risk assessment tool. Rivers carry out a VTE risk assessment on all admitted patients as per Ramsay policy which is based upon the National Institute for Clinical Excellence (NICE) Guidance Our pre assessment team complete a VTE competency assessment via the Department of Health on line assessment tool. VTE Prevention is well served by national standards that facilitate high quality care and NICE guidelines for reducing risk in patients admitted to Hospital. Rivers Hospital is clearly demonstrating the commitment to protecting patients from avoidable harm. Rivers Hospital has taken the following actions to improve this percentage and so the quality of its services; educating the nursing staff to the importance of VTE prevention procedures, and the reasons why these procedures take place. Ward level training sessions for education on the inputting of the data. 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. C. Diff rate: Period Best Worst Average Period Rivers per 100, /13 Several 0 RVW 30.8 Eng /13 NVC bed days 2013/14 Several 0 RMP 32.5 Eng /14 NVC The data made available to the National Health Service trust or NHS Foundation Trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period. 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Rivers Hospital considers that this data is as described for the following reasons; Very high infection rates at the beginning of this century led to concerted efforts by the NHS to reduce numbers, principally by use of mandatory targets for reductions in cases. Rivers has succeeded in Page 29 of 42

30 protecting its patients from the harms of C-diff, and has had 0 cases in the last year. Rivers Hospital intends to take the following actions to maintain this percentage and so the quality of its services, by; The Local IPC Committee is chaired by our Infection Prevention and Control lead and consists of representatives from all areas of the Hospital. The committee meets quarterly to oversee implementation of corporate policies and National guidance and review clinical audit & practice. All staff undertake mandatory infection prevention and control (IPC) training annually Completion of corporate clinical audits, incident reporting, identifying trends and identification of further training requirements Information sharing at Clinical Governance level locally, corporately and with our commissioners. Also through local Medical Advisory Committee and Risk Management meetings. 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, 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 hearing patients and carers throughout the entire system, and at all times. Incident reporting supports clinicians to learn about why patient safety incidents happen within their own service and organisation, and what they can do to keep their patients safe from avoidable harm. SUIs: Period Best Worst Average Period Rivers (Severity 1 only) Oct 13 - Mar 14 RBD 0 R1F 3.72 Eng 0.43 Oct13-Mar14 NVC Apr - Sep 14 Several 0 RBZ 1.09 Eng 0.17 Apr-Sep14 NVC The data made available to the National Health Service trust or NHS Foundation Trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Rivers Hospital has extremely low numbers of SUI, this is attributed to the Hospitals commitment to safe care. The above figures represent severe/death patient safety incidents per 1000 admissions (13/14) or per 1000 bed days (Apr-Sep14). Ramsay utilise the Riskman system to report all patient incidents in real time. All incidents are initially reviewed by the Matron and an investigation process, root cause analysis and action plan are Page 30 of 42

31 implemented where appropriate. The Riskman system immediately reports incidents directly to the Corporate Risk Management Team for central review and recognition of trends. The openness of staff is essential for the delivery of safe high quality care. Effective reporting leads to development of strategies which turn prevent further error and enhance the patients care. Rivers Hospital intends to maintain the low number of SUI s, and so the quality of its services, by: Continuing to promote the importance of accurate reporting of all incidents. Training staff on the Riskman reporting system Monthly Risk management and Clinical Governance meetings are instigated where risk key performance indicators and incidents are discussed and disseminated Continuing staff training in risk assessment of patients Riskman introduction training updates via web based rolling programme Friends and Family Test Patient The NHS Friends and Family Test (FFT) is an opportunity for patients to provide feedback on the Hospitals services. It was introduced in 2013 and asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. This gives the Hospital a better understanding of the needs of their patients and enabling improvements. F&F Test: Period Best Worst Average Period Rivers Feb-15 Several 100% RHU10 75% Eng 94.7% Feb-15 NVC % Friends and Family Test Patient. The data made available by National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2) 4: Ensuring that people have a positive experience of care This indicator is not a statutory requirement. Rivers Hospital considers that this data is as described for the following reasons; NHS England is now calculating and presenting the FFT results as a percentage of respondents who would/would not recommend the service to their friends and family. It can be seen that Rivers has the highest possible % for recommendations. Alongside providing clinical excellence and safe care, patient experience is the key measure of quality. Rivers Hospital intends to take the following actions to maintain this percentage and so the quality of its services by; Continue to raise awareness of staff of the importance of patient feedback by highlighting results through Clinical Governance meetings, staff meetings and Customer Care Excellence training Review the feedback and instigate action plans to address issues highlighted Page 31 of 42

32 3.3 Patient safety We are a progressive Hospital, and focused 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 Rivers Hospital has a very low rate of Hospital Acquired Infection and has had no reported MRSA bacteraemia in more than 6 years. The Department of Health requires mandatory surveillance of specific categories of healthcare associated infections (HCAI). This allows national trends to be identified and can be used as a measure of progress within a Trust and an indicator of standards. 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. In the past year Rivers have had no incidences of any of the alert organisms: MRSA (methicillin resistant staphylococcus aureus) bacteraemia Clostridium difficile infection (CDI). Escherichia coli (E.coli) bacteraemia MSSA (methicilin sensitive staphylococcus aureus) bacteraemia Ramsay participates in mandatory Surveillance of Surgical Site infections for orthopaedic joint Surgery and these are also monitored. We have also extended this surveillance to measure Spine and Total Abdominal Hysterectomy operations Type of Operation %SSI %SSI national Benchmark Total Abdominal Hysterectomy Spine Total Hip Replacement Total Knee Replacement SSI infection rates remain low. There has been a marked reduction in SSI rates for Total Knee Replacement (TKR), from 4% (Q3) to 1.4%. The 1.4% this quarter is attributed to 1 patient. We have also reduced Total Hip Replacement (THR) Infection rate from 1.8% to 0. Both of which are beneath the national benchmark. Page 32 of 42

33 Since October SSI monitoring has been extended to Total Abdominal Hysterectomy (TAH) and Spinal patients. Spines are showing positive results with a 1.8%, again below the benchmark for this procedure. The elevated % SSI for the TAH is attributed to one patient as the data has such low numbers, rendering it statistically unviable. These results support Rivers commitment to patient safety and reduction in harm. 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: Rivers Hospital understands that Infection Control is a core part of an effective risk management programme, aiming to improve the quality of patient care and the occupational health of staff, in addition to the clinical need to prevent Healthcare Associated Infections (HCAI), and protect patients from harm. Rivers infection control processes are coordinated and led by the Infection Prevention and Control nurse. Rivers Hospital Infection Prevention & Control Committee comprises of Consultant Microbiologist, Infection Control Lead; Hospital Matron; Pharmacy link and Theatre manager, and links from all departments including x ray, theatre and house-keeping. Meetings are held quarterly and provide the Hospital with infection prevention advice and guidance in conjunction with Ramsay Infection Prevention & Control Policies and Procedures and National Guidance. All staff undertake mandatory annual e-learning and practical training sessions for Infection Prevention and our Consultant Microbiologist also provides bi-annual in house training. A comprehensive Infection Control Audit Programme has been maintained throughout 2014/2015. Audits undertaken during 2014/2015 achieved the following scores: Audit % Compliance Hand Hygiene 99 Environment Cleanliness 99 Surgical Site Infection 100 Peripheral Venous Catheter Care 99 Urinary Catheter Care 96 Page 33 of 42

34 Infection Rates (percentage of Admissiosns) Infection Rates / / /15 Rivers Hospital Rivers closely monitor all Infections. As can be seen in the above graph our infection control rate has marginally increased over the last year. This can be attributed to the change in reporting culture within the Hospital. As can be seen below we have had a total of 34 infections in the whole year. This figure includes postoperative wound infections and urine infections detected pre-surgery. Hospital Acquired Infections /13 13/14 14/15 Rivers Hospital Page 34 of 42

35 Cleanliness and Hospital hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Rivers 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. Rivers received the following scores during the most recent PLACE audit: CLEANLINESS FOOD OVERALL WARD FOOD ORGANISATION FOOD PRIVACY/DIGNITY WELLBEING % 94.83% % 91.29% 94.34% % Safety in the workplace Safety hazards in Hospitals are diverse, ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. All relevant CAS alerts which require action are reviewed and discussed through Risk, Clinical Governance and Medical Advisory meetings. Rivers have allocated nurses on site who are linked to the wellbeing programme. This ensures the needs of staff are met locally and facilitates close monitoring and robust reporting. All staff members complete a health surveillance programme on appointment of position. Any occupational health issues during employment are tracked through the Riskman reporting system. All staff at Rivers attend mandatory training, this includes: Health and Safety Manual Handling Emergency Fire safety Page 35 of 42

36 Retrnn to Theatre (Percentage of Admissiosns) 3.4 Clinical effectiveness Rivers 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 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. Return to Theatre Score / / /15 Rivers Hospital An operation, however minor, is a serious event and we understand that this can make our patients feel nervous. However, we work hard to ensure all our patients receive the best possible outcome first Page 36 of 42

37 time round. It can be seen in the above graph that Rivers have significantly reduced the returns to theatre rate over the last 2 years. Readmission to Hospital Effectiveness is defined as an organisation s ability to help people to recover from episodes of ill health or following injury. A proxy measure of effectiveness is the rate of emergency readmissions to hospital within 28 days of discharge from that hospital. Between 2002 and 2012, the rate of all emergency readmissions rose from 9% to 11.5% equivalent to a rise of 27%. It can be seen from the chart below that the readmission rate at Rivers is well below this rate, currently at 0.25%. The rise from last year can be attributed to patients accessing the Rivers rather than the Local General Hospital. If a patient is seen post operatively at Rivers and required readmission, they will be admitted straight to a bed. 0.30% Readmissions 0.25% 0.20% 0.15% 0.10% 0.05% 0.00% 12/13 13/14 14/15 Rivers Hospital 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 Rivers to an Acute Hospital would be clinical acuity. It can be seen that very few Transfers take place per 100 discharges. The number has reduced in the last year as we have robust tools used to identify deteriorating patients, reducing the amount of emergency transfers. There is acknowledgement that some transfers cannot be prevented, such as those requiring specialist treatment centres. Page 37 of 42

38 0.25% Transfers 0.20% 0.15% 0.10% 0.05% 0.00% 12/13 13/14 14/15 Rivers Hospital 3.5 Patient Experience All feedback from patients regarding their experiences with Ramsay Health Care are welcomed and inform service development in various ways dependent on the type of experience (both positive and negative) and action required to address them. All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour letters and cards are displayed for staff to see in staff rooms and notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. All negative feedback or suggestions for improvement are also feedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care. Patient experiences are feedback via the various methods below, and are regular agenda items on Local Governance 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 Page 38 of 42

39 Satisfaction Scores Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/ s Patient focus groups PROMs surveys Care pathways patient are encouraged to read and participate in their plan of care Patient Satisfaction Surveys Our patient satisfaction surveys are managed by a third party company. 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 (inpatient or outpatient) is asked their consent to receive an electronic survey or phone call after they leave 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. Satisfaction Scores NHS/Private Patients / /15 Rivers Hospital It can be seen above that the satisfaction score has reduced from last year. The overarching negative comments were regarding the lack of car parking. This was resolved early Having added further parking to the site we are expecting that this score will improve by the next report. Page 39 of 42

40 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% Patient Satisfaction It can be seen from the chart above that Patient Satisfaction is greater than 93% in all areas across the Hospital. This is extremely positive and proof of the hard work and commitment staff have for delivering a high quality service that is safe from harm. Page 40 of 42

41 Appendix 2 Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month. Page 41 of 42