Blakelands Hospital. Quality Account 2014/15

Transcription

1 Blakelands Hospital Quality Account 2014/15

2 Contents Introduction Page Welcome to Ramsay Health Care UK Introduction to our Quality Account PART 1 STATEMENT ON QUALITY 1.1 Statement from the General Manager 1.2 Hospital accountability statement PART Priorities for Improvement Review of clinical priorities 2014 / to 2015(looking back) Clinical Priorities for 2015/16 (looking forward) 2.2 Mandatory statements relating to the quality of NHS services provided Review of Services Participation in Clinical Audit Participation in Research Goals agreed with Commissioners Statement from the Care Quality Commission Statement on Data Quality Stakeholders views on 2014/15 Quality Accounts PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 The Core Quality Account indicators 3.2 Patient Safety 3.3 Clinical Effectiveness 3.4 Patient Experience 3.5 Case Study Appendix 1 Services Covered by this Quality Account Appendix 2 Clinical Audits

3 Welcome to Ramsay Health Care UK Blakelands Hospital is part of the Ramsay Health Care Group The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals. We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning 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 out 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 3 of 38

4 Introduction to our Quality Account This Quality Account is Blakelands Hospitals annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on. Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this didn t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share. Page 4 of 38

5 Part Statement on quality from the General Manager Julie Fraser, General Manager Blakelands Hospital As the General Manager of the Blakelands Hospital I am passionate about ensuring that we deliver consistently high standards of care to all of our patients. Our Hospital Vision is that;- As a committed team of professional individuals we aim to consistently deliver quality holistic Acute Day Case Services with exemplary customer care. This we believe we are able to achieve by continually updating our staffs skills and competencies. We strive to further develop our knowledge in order to deliver evidenced based clinical practice. Our Quality Account details the actions that we have taken over the past year in order to ensure that our high standards in delivering patient care are maintained and for those areas where we have identified as requiring improvements, these have been actioned. We have implemented changes to our processes in order to deliver high standards of care some changes include updated patient discharge information, updating letters sent to patient for out-patient appointments to include more information about what to expect, implementing Friends and Family for outpatients and Physiotherapy patients and standardising dressing regimes. Our hospital has a strong track record of safety and high standards of care, which we share with our local CCG. Page 5 of 38

6 Our Quality Account has been produced to provide accurate information about how we monitor and evaluate the quality of the services that we deliver throughout our Hospital. We hope to be able to share with the reader our progressive achievements that have taken place over the past year. Blakelands Hospital has a very strong track record as a safe and responsible provider of Day Case services and we are proud to share our results. To ensure that we continue to deliver clinical excellence involves everyone in our Hospital. Every individual member of staff is crucial to the success of our Hospital and they value the contribution that they make in delivering great customer care we have a training and education plan which involves all members of our administrative and clinical teams. Our Quality Accounts have been developed with the involvement of our staff who have been very much engaged with developing a systems approach to risk management which focuses on making every effort to reduce the likelihood and consequence of an adverse event or outcome associated with treatment of a patient. To ensure a coordinated approach to the delivery of care for patients and to monitor the adherence to professional standards and legislative requirements the Clinical Governance Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and safety performance of the Hospital. These committees have reviewed and commented on the details within this Quality Account. If you would like to comment or provide me with feedback then please do contact me on julie.fraser@ramsayhealth.co.uk. Or contact me on Page 6 of 38

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. Julie Fraser General Manager Blakelands Hospital Ramsay Health Care UK This report has been reviewed and approved by: Mr. Cyril. Marek Medical Advisory Committee Chair( MAC ) Mr James Beech Midland regional Director Milton Keynes Clinical Commissioning Group Health watch Milton Keynes Page 7 of 38

8 Welcome to Blakelands hospital Blakelands Hospital is a purpose built day case unit which was opened in It was designed to combine an exceptional standard of patient day case facilities with the technical equipment that modern medicine demands. The Centre provides NHS and private day care facilities for: General Surgery Ophthalmic Surgery including YAG Laser Orthopaedic Surgery Upper and lower diagnostic Endoscopy procedures, including direct referrals Podiatric Surgery Physiotherapy including Shockwave Therapy. Acupuncture We provide safe, convenient, effective and high quality treatment for adult patients (excluding children below the age of 18 years), whether privately insured, self-pay, or from the NHS. A high percentage of our patients are referred from the NHS sector, patients choosing to use our facility through Choose and Book. Our services help to ease the pressure on Milton Keynes General Hospital and NHS facilities and we have worked closely with the Hospital Management Team and the Clinical Commissions Group (CCG) to ensure improved access for patients requiring day case surgery, diagnostics and physiotherapy. We are one of the approved providers for Acupuncture for local people referred from the Pain Clinic at Milton Keynes General Hospital. We have close links with GP surgeries, providing information, training and liaison in order to monitor their needs and the requirement of the local population. We have carried out over 2,319 procedures in the past 12 months of which 97% are for NHS Patients. We currently employ the following staff at the Blakelands Hospital;- Consultant Orthopaedic Surgeon, a Consultant Anaesthetist and a Consultant Endoscopist. We also have consultants who work on a regular basis and these include Consultant Ophthalmologist, Consultant General Surgeons and Consultant Radiologist, and Consultant Podiatrists. Page 8 of 38

9 1 Matron, 7 Registered Nurses and an Operating Department Practitioner and 1 Health Care Assistant 1 Radiologist and 1 Physiotherapist 6 Administrators, 1 PA/HR Coordinator 1 Supplies Co-coordinator and a Maintenance Assistant Sales and Marketing/GPL coordinator 6 Sterile Services Technicians 2 House Keeping Staff Blakelands Hospital employs a GP Liaison Officer (GPL) who maintains and establishes relationships with GP s and the practice staff from Milton Keynes Surgeries and the surrounding areas. A GP visit schedule is maintained whereby surgeries are contacted and visited every month. GP s are sent regular newsletters and updates via and hard copies are also delivered. Information packs containing information, about the Hospital and how to refer are distributed via mail or during the visits held at the surgeries. Educational visits are set up during practice learning times whereby the consultant and GP Liaison Officer will visit GP s with a topic of interest for a Lunch & Learn session. GP Educational evenings are also held at the Hospital. GP s, Practice Managers and Medical Secretaries are invited and attend regular Choose and Book workshops at the Hospital. The following table lists all of the surgeries in Milton Keynes. Each surgery has been visited and has received an informationl pack of information about the Hospital. BROUGHTON GATE HC CMK MC COBBS GARDEN SURGERY DRAYTON ROAD SYRGERY - FISHERMEAD MC GROVE SURGERY HILLTOPS MC KINGFISHER SURGERY - MK VILLAGE SURGERY - NEALTH HILL HC NEWPORT PAGNELL MC - PARKSIDE Page 9 of 38

10 PURBECK HC RED HOUSE SURGERY - SOVEREIGN MC STANTONBURY HC STONEDEAN PRACTICE - STONY STRATFORD HC - WALNUT TREE HC WATER EATON HC WATLING VALE MC WESTCROFT HC - WESTFIELD ROAD SURGERY - WHADDON MEDICAL CENTRE WILLEN VILLAGE SURGERY - WOLVERTON HC ASHFIELD MC BEDFORD STREET SURGERY Outside activities include hosting Patient Participation Group meetings, meeting with group members and discussing services provided at the hospital. Meeting with members from Healthwatch Milton Keynes and involving them in the Patient Led Assessment of the Care environment (PLACE) audits and presenting patient experiences at Milton Keynes CCG Board meeting. The Hospital also promotes its services to the community via advertising in local publications such as the GP magazines, MK live and local radio. Page 10 of 38

11 Part Quality priorities for 2014/2015 Plan for 2014/15 On an annual cycle, Blakelands Hospital develops an operational plan to set objectives for the year ahead. We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services. To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital. Priorities for improvement A review of clinical priorities 2014/15 (looking back) Changes to Ramsay s National Audit Programme ensure that patients who are at risk of their condition deteriorating receive the very best care by means of an early warning score. This specific auditing of the medical records of this group of patients has now been implemented. This ensures that all aspects of the service delivery can be reviewed and changes implemented so that the best and most safe outcomes are achieved. One Clinical Priority for 2104 was to increase the number of staff trained on the Page 11 of 38

12 Advanced Life Support training, to recognise deteriorating patients and manage medical emergencies and maintain patient safety. There are several staff trained on the ALS and all clinical staff are trained on the ILS, Intermediate Clinical Support at Blakelands Hospital. We are also encouraging all Consultants who work at the Hospital to undertake the ILS course. Staff also attend the Acute Illness Management course to help recognise the deteriorating patient. Staff Survey 2013 The results of the staff survey for 2013 was excellent, Blakelands Hospital come top of several aspects with the Ramsay region and third highest hospital score overall. The Staff engagement group has been formed to review the results and identify areas of improvement for staff, this is working well and ensures staff are listened to and suggestions considered. Pain management Through the patient survey we will gather information on how well patient pain was controlled and that they thought staff did everything they could to help control their pain. Quarterly audits have taken place and results have shown that overall patients have been satisfied with their pain management. Staff have attended pain management courses to enhance their knowledge and update their skills. Discharge information Through the patient survey we will gather information that patients were given written information about what they should or should not do following their procedure. Quarterly audits have taken place and results have shown that overall patients have been satisfied with their discharge information Some patient information leaflets have been updated Clinical Priorities for 2015/16 (looking forward) Patient safety One of the dimensions of quality is that we do no harm to patients, this means ensuring the environment is safe, clean and reducing unavoidable harm. Venous thromboembolism We follow NICE guidelines to ensure patients are assessed and given the appropriate prophylaxis to avoid VTE s. This is a requirement of the national and local Page 12 of 38

13 Commissioning for Quality and Innovation (CQUIN). Through robust audit and reports we will ensure we are 100% Compliant. Surgical Safety Checklist Safer surgery is a priority at the hospital. The surgical safety checklist is a tool devised by the World Health Organisation to ensure theatre checks are carried out through the patient s theatre journey. Through our robust clinical governance audit program, we will continue to ensure every patient undergoing surgical procedure (including Local anaesthesia) has the WHO checklist completed and entered in clinical notes by a registered member of the team. Clinical Effectiveness Consent process One of the local CQUINS for the coming year is to ensure patients receive the correct information prior to giving consent for surgery and an opportunity to ask questions. Through patient surveys we will gather information to ensure a process for healthcare intervention will ensure the patient has been given all information in terms of what the treatment involves, including benefits and risks. Hand Hygiene Infection and prevention control is a priority, all staff receive training and updates on hand hygiene. We will continue to perform monthly and quarterly audits and participate in national hand hygiene awareness events. Friends & Family At Blakelands hospital we place feedback from our patients at the very heart of our service. Friends and Family is one of the national CQUINS and Blakelands Hospital has achieved 100% compliant collecting data to ensure patients feedback is collected and communicated to staff. Our friends and family questionnaires and external audits gives us the feedback required to improve and review our services. We operate a complaints process that responds, flexibly, open and honesty to the patient s concerns or complaints, which enables us to support complaints effectively and promote public confidence in our service. Page 13 of 38

14 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 the Hospital provided and/or subcontracted 6 NHS services. Blakelands Hospital has reviewed all the data available to them on the quality of care in 6 of these NHS services. The income generated by the NHS services reviewed in 1 April 2014 to 31 st March 2015 represents 99.9% per cent of the total income generated from the provision of NHS services by the Blakelands Hospital hospital/centre for 1 April 2014 to 31 st March 2015 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 Staff Cost % Net Revenue 24.28% HCA Hours as % of Total Nursing 15.80% Page 14 of 38

15 Agency Cost as % of Total Staff Cost 21.18% Ward Hours PPD 0 % Staff Turnover 23.3 % Sickness 1.90% % Lost Time 16.02% Appraisal % 100% Mandatory Training % 83% Staff Satisfaction Score 4.86 Number of Significant Staff Injuries 3 Patient Formal Complaints per 1000 HPD's 2.24 Patient Satisfaction Score 94.9% Significant Clinical Events per 1000 Admissions 5.75 Readmission per 1000 Admissions 0.64 Quality Workplace Health & Safety Score 98% Infection Control Audit Score 100% Participation in clinical audit During 1 April 2014 to 31 st March 2015 Blakelands Hospital didn t participate in national clinical audits as we either didn t undertake the procedures or have enough patient activity to warrant participation. Local Audits Page 15 of 38

16 The reports of 70 local clinical audits from 1 April 2014 to 31 st March 2015 were reviewed by the Clinical Governance Committee and Blakelands Hospital intends to take the following actions to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. Pharmacist visit to educate staff on Controlled Drugs requisition documentation Care pathway review undertaken Provision of Hand Hygiene leaflets and displayed in all clinical areas Participation in Research There were no patients recruited during 2014/15 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 Blakelands Hospital income in from 1 April 2014 to 31 st March 2015 was conditional on achieving quality improvement and innovation goals agreed Blakelands Hospital and any person or body are entered into a contract, agreement or arrangement for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2014/15 and for the following 12 month period are available on request Statements from the Care Quality Commission (CQC) Blakelands Hospital is required to register with the Care Quality Commission and its current registration status on 31 st March is registered without conditions/registered with conditions. Blakelands Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. A positive unannounced inspection was carried out by the CQC in February 2014; all areas reviewed in the inspection conclude full compliance Data Quality Page 16 of 38

17 Statement on relevance of Data Quality and your actions to improve your Data Quality The hospital successfully passed the ISO external audit in March Blakelands Hospital will be taking the following actions to improve data quality. Archiving of information to a secure off site storage. All offsite storage has been logged and boxed to ensure we have access as required. NHS Number and General Medical Practice Code Validity Information Governance toolkit levels Data Quality Statements 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: Ramsay Group Information Governance Assessment Report score overall score for 2014/15 was 96% and was graded green (satisfactory). Page 17 of 38

18 Clinical coding error rate Blakelands Hospital was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission. Page 18 of 38

19 2.2.7 Stakeholders views on 2014/15 Quality Account Comments from Health Watch Milton Keynes Thank you for forwarding the Quality Account which we found to be very informative. The data collected clearly shows that your internal arrangements are working well, with high levels of care and positive outcomes for your patients including those who are receiving treatment though your NHS contracts - 95% of the total numbers. Page 19 of 38

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21 Part 3: Review of quality performance 2014/2015 Statements of quality delivery Matron, Janet Brackley Review of quality performance 1st April st March 2015 Introduction 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 Page 21 of 38

22 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 this model are: Infrastructure Culture Quality methods Poor performance Risk avoidance Coherence Page 22 of 38

23 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 23 of 38

24 3.1 The Core Quality Account indicators:- Mortality 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 Period Best Worst Average Period Blakelands Jan13-Dec13 RKE 0.62 RXL 1.18 Eng /14 NVC31 0 Apr13-Mar14 RKE 0.54 RBT 1.20 Eng /15 NVC31 0 The Blakelands hospital considers that this data is as described for the following reasons:- We have not had any reported deaths since facility opened in 2007 Patient Reported Outcomes Measures (PROMS) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s patient reported outcome measures scores for (i) groin hernia surgery, (ii) 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 Page 24 of 38

25 Hernia Period Best Worst Average Period Apr13 - Mar14 Apr14 - Sep14 Veins NT41 5 RXR NVC11 Severa l En g En g Apr13 - Mar14 Blakeland s NVC31 * Apr14 - Sep14 NVC31 * Period Best Worst Average Period Apr13 - Mar14 RT H NT35 0 Apr14 - Sep14 RYJ RWA En g En g Apr13 - Mar14 Apr14 - Sep14 Blakeland s NVC31 NVC31 Hips Period Best Worst Average Period Apr13 - Mar14 Apr14 - Sep14 NT44 1 RCB RQ X RJD En g En g Apr13 - Mar14 Apr14 - Sep 14 Blakeland s NVC31 NVC31 Knees Period Best Worst Average Period Apr13 - Mar14 Apr14 - Sep14 NT NV32 3 RWP RXF En g En g Apr13 - Mar14 Apr14 - Sep14 Blakeland s NVC31 NVC31 The Blakelands Hospital considers that this data is as described for the following reasons:- Out of the above procedures, only groin Hernia repairs are performed at this hospital with insufficient quantities to produce a PROMS (Patient reported Outcome measures) score. Patients are however encouraged to participate in the study. Page 25 of 38

26 Readmissions 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 0.70 Readmissions per 1000 HPDs Series / / / / / /15 The Blakelands hospital considers that this data is as described for the following reasons Readmsissions per HPD s ( Hospital patient days) As a day unit we are made aware of any readmission via the postoperative follow up call and the out of hour s helpline. There has been 2 patients readmission to hospital in the last year which has been reported on our Riskman incident reporting tool and reviewed at clinical governance meetings. Page 26 of 38

27 Responsiveness to people s needs The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust s responsiveness to the personal needs of its patients during the reporting period. 4: Ensuring that people have a positive experience of care Period Best Worst Average Period Renacres 2012/13 RPC 88.2 RJ Eng /14 NVC /14 RPY 87.0 RJ Eng /15 NVC The Blakelands hospital considers that this data is as described for the following reasons As a day unit facility we do not qualify for this survey, however we do participate in an external research survey and score highly VTE assessments (Venous thromboembolism) 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 Period Best Worst Average Period Blakelands 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 % The Blakelands hospital considers that this data is as described for the following reasons:- Page 27 of 38

28 The scores are higher than the national average in compliance with VTE assessment. Nurses participate in VTE assessment Clinicians are encouraged to complete VTE assessment and update on the postoperative notes C difficile rate :- per 100,000 bed days 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 Period Best Worst Average Period Blakelands 2012/13 Several 0 RVW 30.8 Eng /13 NVC /14 Several 0 RMP 32.5 Eng /14 NVC The Blakelands hospital considers that this data is as described for the following reasons:- Good infection control and prevention measures in practice No incidents of C-Diff Serious Incidents level 1 only 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 Period Best Worst Average Period Blakelands 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 Blakelands hospital considers that this data is as described for the following reasons Page 28 of 38

29 No reported Seriious incidents severity 1. F&F Test 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. Period Best Worst Average Period Renacres Jan-15 Several 100% RPA % Eng 94.0% Jan-15 NVC % Feb-15 Several 100% RHU10 75% Eng 94.7% Feb-15 NVC % The Blakelands hospital considers that this data is as described for the following reasons:- Blakelands consistently score extremely likely to friends and family The score reflects the response rate which has declined due to patients being asked the question several times during their hospital experience on the inpatient and out-patient visits. The Blakelands hospital will continue to invite patients to participate in the survey 3.2 Patient safety We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety. Page 29 of 38

30 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 Blakelands hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 3 years. We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents year on year. Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored. Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a Corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year. A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice. Programmes and activities within our hospital include: At Blakelands hospital we have a dedicated infection control nurse who is involved in the yearly infection control surveillance, hand hygiene, surgical site infection and environmental audits. A network of link nurses meet regularly to improve clinical practice. Our (IPC) Committee meet regularly. Group policy is revised and re-deployed every two years. The local infection control committee produce an annual plan in line with the corporate IPPC recommendations. Page 30 of 38

31 Infection Rates (percentage of Admissiosns) Infection Rates / / /15 Blakelands Hospital We have a small increase in infections this year through raising awareness and a more robust reporting system. Through Root cause analysis investigation, we have no trends identified, actions required have been implemented. Infection control is a priority for the hospital any signs of infection are reported on the riskman incident reporting tool Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Blakelands 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. Results of Patient Led Assessment of the Care Environment audit 2014 Page 31 of 38

32 In 2014 a representative from Healthwatch Milton Keynes and an ex patient formed part of the assessment team. Our results are as below:- Cleanliness 100% Higher Than the national average score. Food 66.67% We do not have catering facilities at Blakelands hospital, therefore reflected in the score Privacy & Dignity 87.73% Some of the measurements assessed do not apply to a day unit facility. As we do not provide individuals with TV, radio and internet access, this is reflected in our scores. Condition, appearance and maintenance 98.72% Higher than the national average score. Some blinds required attendance. We do have a robust maintenance programme in place Safety in the workplace Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. Page 32 of 38

33 Retrnn to Theatre (Percentage of Admissiosns) Safety alerts on equipment, products and medicines are cascaded and communicated throughout the hospital. Health and safety and the safer sharps has progressed with products, in house training and staff awareness. The WHO checklist is integral to daily practice in theatre. Training, education and audits ensure compliance. 3.3 Clinical effectiveness Blakelands 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 Return to Theatre Score / / /15 Blakelands Hospital 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. Page 33 of 38

34 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. In the last 12months one patient was transferred to theatre at the local NHS trust following a surgical complication. 3.4 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 fedback 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 fedback via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy. Feedback regarding the patient s experience is encouraged in various ways via: Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48hrs of a patient making a comment on their web survey Yearly CQC patient surveys Friends and family questions asked on patient discharge We value your opinion leaflet Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/ s Patient focus groups PROMs surveys Care pathways patient are encouraged to read and participate in their plan of care Page 34 of 38

35 3.3.1 Patient Satisfaction Surveys Our patient satisfaction surveys are managed by a third party company called Qa Research. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient s views. Every patient (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 % Patient Satisfaction 100.0% 80.0% 60.0% 40.0% Patient Satisfaction 20.0% 0.0% 2009/ / /14 Page 35 of 38

36 Appendix 1 Services covered by this quality account All Day case patient, out-patients, Radiology and Physiotherapy General Surgery Ophthalmic Surgery including YAG Laser Orthopaedic Surgery Upper and lower diagnostic Endoscopy procedures, including direct referrals Podiatric Surgery Physiotherapy including Shockwave Therapy. Acupuncture Page 36 of 38

37 Appendix 2 Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month. Page 37 of 38

38 Blakelands hospital Ramsay Health Care UK We would welcome any comments on the format, content or purpose of this Quality Account. If you would like to comment or make any suggestions for the content of future reports, please telephone or write to the General Manager using the contact details below. For further information please contact: Hospital Page 38 of 38