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Oaklands Hospital

Quality Account 2015/16

ContentsIntroduction 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 2

2.1 Priorities for Improvement

2.1.1 Review of Clinical Priorities 2015/16 (looking back)

2.1.2 Clinical Priorities for 2016/17 (looking forward)

2.2 Mandatory Statements Relating To The Quality Of NHS Services Provided

2.2.1 Review of Services

2.2.2 Participation in Clinical Audit

2.2.3 Participation in Research

2.2.4 Goals Agreed with Commissioners

2.2.5 Statement from the Care Quality Commission

2.2.6 Statement on Data Quality

2.2.7 Stakeholders Views on 2015/16 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account Indicators

3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

Appendix 1 – Services Covered by this Quality AccountAppendix 2 – Clinical Audits

Welcome to Ramsay Health Care UK

Oaklands Hospital is part of Ramsay Health Care 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 thousands of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Groups, NHS Trusts and NHS referral management and triage services.

Statement from our Chief Executive Officer

“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 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 reputation as a major provider of healthcare services across the world and of our 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

Quality Accounts 2015/16 of 44

Introduction to our Quality Account

This Quality Account is Oaklands Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and reports on the period 1st April 2015 to 31st March 2016. It also 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 patients’ 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, developed by our Corporate Office, summarised and reviewed quality activities across every hospital within Ramsay Health Care UK. It was recognised that this didn’t provide enough in-depth information for the public and for 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.


Part 1

1.1 Statement on Quality from the General Manager

This is the fifth Quality Account to be submitted by Oaklands Hospital and has been produced to demonstrate our commitment to measuring all feedback from patients about their experience, clinical treatment and clinical outcomes. This allows us to continually review, reflect on and improve the patient’s journey.

Patient safety is our highest priority and our robust recruitment processes and training programmes ensure that staff are competent and fully trained in all aspects of service provision.

We achieve consistently high patient satisfaction scores and, by studying results throughout the year, we constantly seek ways to further improve the patient experience.

Whilst patient feedback and involvement is extremely important to us, we also rely heavily on other measures of safety and clinical effectiveness which we use to satisfy ourselves that treatment is evidence-based and delivered by appropriately qualified and experienced doctors, nurses and other key healthcare professionals. Examples of these are detailed in this Quality Account.

As General Manager of Oaklands Hospital, I am passionate about ensuring that high quality patient care is our number one priority. Our Quality Account is an accurate representation of our performance and our ongoing initiatives to continuously improve the quality of our services.

Helen Rocca, General ManagerOaklands Hospital


1.2 Hospital Accountability StatementTo the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.

Helen Rocca, General ManagerOaklands Hospital, Ramsay Health Care UK

This report has been reviewed and approved by:

Mr Henry Maxwell, Consultant Surgeon and Chair Medical Advisory Committee, Oaklands Hospital

Helen White, Regional Director, Ramsay Health Care


Welcome to Oaklands HospitalOaklands Hospital is one of Greater Manchester's leading private hospitals with a reputation for delivering high quality healthcare treatments and services. Located in Salford, the hospital is close to the A580 and the M602.

The hospital opened in 1990 and is registered for 26 patient rooms, (16 bedrooms, an 8-bedded day case facility and a 2-bedded High Dependency Unit. )

Oaklands Hospital has 3 Theatres with laminar flow ,and 1 Minor Ops/Endoscopy Suite.

Patients requiring level-2 care are treated and cared for by a well-trained team of staff in a dedicated area prior to transfer to a critical care facility.

Children under the age of 16 are seen in the Outpatient Department for Consultation only purposes and in patient care and treatment for young persons over 16 years. Oaklands Hospital is part of the Greater Manchester Critical Care Network and has a Service Level Agreement in place with Royal Manchester Children’s Hospital if transfer of a child is required.

Oaklands Hospital provides fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of three years for inpatient care) whether medically insured, self-funding or from the NHS. The Hospital offers a comprehensive range of treatments and services including ENT procedures, Maxillofacial Surgery, Cosmetic Dentistry, Plastic Surgery, Dermatology Gynaecology, General Surgery, Orthopaedics, Ophthalmic and Urological procedures.

Diagnostic facilities include CT, barium studies, ultrasound, MRI and DEXA for bone density, in addition to general radiology.

All of the Hospital’s consultants are highly experienced and have patient care and comfort as their highest priority. All patients have the reassurance that a resident doctor is available 24 hours/day.

Our physiotherapy clinic is staffed with Chartered, HCPC registered physiotherapists.


Oaklands Hospital is part of the Greater Manchester Critical Care Network and has a Service Level Agreement in place with Royal Manchester Children’s Hospital if transfer of a child is required.


Part 2

2.1 Performance against our Clinical Priorities for 2015/2016 looking back

Patient SafetySurgical Safety Checklist – This is a set of criteria produced by the World Health Organisation set to improve the safety of surgery.

There have been no ‘Never Events’ at Oaklands Hospital in the period and audit of compliance maintains a key focus with monthly audit of WHO safety checklists. Audits are reviewed by the Hospital’s Clinical Governance and Medical Advisory committees with any non- compliances recorded and action plans put in place.

NHS Safety Thermometer – We have continued to submit data in relation to The NHS Safety Thermometer which allows us to measure, monitor and analyse patient harm and ensures ‘harm free care’. External audit has demonstrated 100% compliance.

VTE Assessment – A VTE assessment is completed for all patients to reduce the incidence of post- operative Venous Thromboembolism (VTE), this is in accordance with Ramsay Policy CM 001 VTE policy and during the past year documentation has been at 97.7% average compliance, the key performance target being 95%.

Staffing – Retention and recruitment of clinical staff within Theatres and the Ward has been a key focus over the period as it has been nationally within Healthcare. At Oaklands Hospital the Senior Management Team and Heads of Department have taken a key role in ensuring a positive and effective induction for new staff. The electronic system “Allocate” which was introduced in 2014 continues to ensure that safe staffing and necessary skill mix is maintained.

Staff education and development is managed via the Ramsay Academy and onsite training on site as follows:

Mandatory training to maintain clinical competencies Development of individual skills and knowledge Non Clinical training

Staff participated in a Personal Development Review to appraise their performance and review training and development needs. Heads of Departments and Senior


Managers participated in 360 degree feedback from their colleagues on their performance.

Clinical Effectiveness

JAG Accreditation (Joint Advisory Group on Gastrointestinal Endoscopy.)

Due to the development of the new Day Case Unit and third theatre at Oaklands, which included the building of a new Endoscopy suite, working towards JAG accreditation has had to be put on hold and will become a focus for the next period.

PLACE (Patient led assessment of the care environment) –is a patient led audit undertaken by an assessment team that consists of at least fifty per cent patient representation. The audit includes all internal and external areas of the hospital. The scoring matrix employs a system whereby areas are given a ‘Pass’, ‘Fail’ or ‘Qualified Pass’.

The following is an overview of the scores achieved:

• Cleanliness – 100%

• Food –71.65%

• Privacy –90.48%

• Condition –94.26%

The PLACE assessment was took place on May 23rd 2016 with patient representatives performing the assessment with members of Oaklands Hospital Management team. An action plan was put in place for the areas requiring improvement as indicated in the scoring above. Public bodies including the Care Quality Commission, The NHS Commissioning Board and the Department of Health use information from PLACE assessments to ensure that all patients are given a high quality service.

2.1.6 Patient Satisfaction Survey – In the period, Oaklands Hospital Hall continued to encourage patients to provide feedback using various methods which included our:

Web based satisfaction survey Friends and family paper survey ‘We value your opinion’ paper surveys Endoscopy specific paper surveys


Our survey covers all departments to ensure the whole Hospital is included .Patient feedback is recorded and reviewed at the following Hospital groups:

Clinical Governance Committee Heads of Departments Lessons Learnt group Medical Advisory Group Departmental meetings

Our focus has been on implementing, evaluating and improving the new Day Case process listening to our patients and staff and this will continue over the next year in line with our CQUIN to improve the patient experience.

CQUINS 2015/16

The Commissioning for Quality and Innovation (CQUIN) payment framework enables NHS commissioners to reward excellence, by linking a proportion of a healthcare provider’s income to the achievement of quality improvement goals. The National CQUINS were not applicable to Ramsay Hospitals for this year for the reasons given below:

1. Identification and early treatment of sepsis – the total number of patients presenting to the Emergency Department who were screened for sepsis.Not applicable to Ramsay, emergency care only.

2. Care of patients with Acute Kidney Injury – percentage of patients with AKI treated in hospital whose discharge summary includes the response to 4 key questions regarding post op care. Rarely would Ramsay treat a patient with AKI due to our contracted case mix.

3. Improving urgent and emergency care across local health communities.All indicators under this scheme relate to urgent and emergency care services and are therefore not applicable to Ramsay.

LOCAL CQUINS

Pathway redesign, OutpatientsThe key priority for the delivery of Oaklands local CQUIN was to ensure that a difference was made to the patient experience, taking into account patient and staff feedback.The CQUIN will be delivered over two years in line with the refurbishment and extension to the building at Oakland's Hospital. At the end of year one The Hospital


carried out a full review of the day case patient pathway, and after evaluation some changes have been made to increase efficiency and improve patient experience. Patients, staff and Consultants have contributed to the decisions around the changes and in particular patient feedback was most useful during one to one meetings with Matron.

2.1.2 Quality Priorities for 2016/2017 looking forward We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services.

To meet these aims, we have various initiatives ongoing at any one time. The priorities are determined by the 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

Quality Management

In May 2016 Oaklands Hospital appointed a Quality Improvement Lead who will be responsible for consolidating the control of all aspects of quality within the Hospital. Reporting directly to Matron this new role will also allow the departmental managers to be supported in continuous improvement processes and ensuring lessons learnt remains an integral part of the Governance agenda.

The role will include focusing on:

Clinical Governance

Policy management

Audit programme

Customer satisfaction/Management of complaints


Quality Accounts

CQC CQUINS Communication Risk

Success of the role will be evidenced by the achievement of the following:

Availability of key reports for internal and external organisations Availability of all documentation and reports for Clinical Governance meetings Robust action plans, well documented and shared following mandatory audits Root cause analysis and lessons learnt are reported and shared A Quality Account is published annually

Staff Retention and Development

Staffing and retention of staff is vital to clinical quality and will remain a key focus area for Oaklands Hospital and Ramsay Healthcare. A comprehensive and effective induction is essential in supporting employees to fulfil their responsibilities and helps nurture staff for the future. The corporate Human Resource team has been employed to support all managers in Oaklands Hospital with this process.

Ensuring we maintain the correct numbers of appropriately skilled staff available to care for our patients is another key focus and Ramsay’s national Academy provides a dedicated, learning resource consisting of national and regional training courses using internal and external trainers; e-learning tools and support towards formal qualifications. Mandatory training for clinical competencies are incorporated into a training matrix for staff and complemented with webinars and external training. Ramsay’s Management Development Framework also provides opportunity for aspiring leaders of the future to develop their skills and knowledge.

All staff undergo a Personal Development Review (PDR) every year to appraise their performance and set goals for the following 12 month period.

Nurse Revalidation commenced in April 2016, and in order to support our nurses through the process Ramsay has purchased an online system for all employed nurses to assist them with revalidation (i-HeART). Ramsay have also provided 2 training videos, had webinars about revalidation and supplied each member of nursing staff with a memory stick which has instructions help advice on revalidation. Oaklands Hospital will ensure their nurses are supported through this.

Staff engagement, comments are suggestions are really important to us. In February 2016 our staff were asked to participate in ‘My voice staff engagement survey’. The


results from this will be reviewed and an action plan developed, with the support from our corporate Human Resource team, for 2016/17.

Patient Safety:

CQC

The CQC set out a new vision and direction for their strategy for 2013-2016, Raising standards, putting people first, and in their consultation, A new start, which proposed radical changes to the way they regulate health and adult social care services. A new start set out the new overarching framework, principles and operating model that they will use. This includes the five key questions that will be asked of all services:

• Are they safe? • Are they effective? • Are they caring? • Are they responsive? • Are they well-led?

Oaklands Hospital has welcomed the proposals, which include a more robust approach to registration; the introduction of chief inspectors; expert inspection teams; ratings to help people choose care; a focus on highlighting good practice; and a commitment to listen better to the views and experiences of people who use services. The CQC has indicated that all independent hospitals will have been inspected by the end of 2016.

Duty of Candour

The introduction of a statutory Duty of Candour is an important step towards ensuring the open, honest and transparent culture that was lacking at Mid Staffordshire NHS Foundation Trust. The aim of this regulation is to ensure that providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology. At Oaklands Hospital we promote a culture that encourages candour, openness and honesty at all levels.

Information Security

Oaklands Hospital will undergo the independently audited Information Security quality standard ISO 27001 in August 2016.


Safeguarding / PREVENT

Safeguarding vulnerable adults and children is high on our agenda at Oaklands Hospital. A training calendar is in place for the coming 12 months and relevant topical information is displayed on the hospital’s Safeguarding noticeboard and cascaded to all staff with resources for learning and practice development. Safeguarding training is included in all employees’ annual mandatory training and mandatory e-learning modules.

During this period following Safeguarding concerns raised and recorded on our Incident Reporting tool RISKMAN, Root Cause Analysis have been conducted and reported to the appropriate Governing Bodies and include CQC and Salford Adult Safeguarding Team. Appropriate policies have been reviewed and following Root Cause Analysis the relevant measure where put in place as Lessons Learnt.

Clinical Effectiveness:

NICE Guidance / Alerts

Oaklands Hospital has a robust system to receive, review and action all medical alerts which are circulated by the NHS National Patient Safety Agency and will continue to make this a clinical priority. Medical alerts cover a wide range of topics, from vaccines to patient identification. Types of alerts include Rapid Response Reports, Patient Safety Alerts and Safer Practice Notices.

Patient Experience:

Patient Experience

We will continue to encourage patients to provide feedback using our independently collated, web based satisfaction survey. This online survey has been expanded to include outpatients (including physiotherapy and radiology) and also now has specific endoscopy questions. This reduces the need for paper surveys in these areas and duplication of patient questionnaires. We will continue to monitor posts on NHS choices

Due to an increasing number of patients being invited to comment (and the subsequent increase in data and analysis), the independent company that is contracted to undertake the survey for Ramsay, QA Research, will now produce two reports every month and every quarter – one collective report for all Ramsay hospitals and one for each hospital’s own results. ‘Hot Alerts’ i.e. a patient comment


that requires immediate management attention are received and reviewed by the Hospital’s General Manager, Matron, Operations Manager, Quality improvement lead and Head of Departments with action being taken where there are areas identified for improvement. Lessons learnt from patients’ comments and the subsequent introduction of new processes are shared in the hospital and across Ramsay’s other hospitals. All comments, positive and negative, are shared with clinical and non-clinical teams. Compliments and complaints are also reviewed at the hospital’s Clinical Governance and Medical Advisory Committees.

Matron will continue with daily ward rounds to meet with patients and discuss any concerns they may have and also to share positive comments with the Hospital staff

This year the Patient Experience Manager, NHS Salford Clinical Commissioning Group (CCG) will conduct a Patient Experience Feedback day at Oaklands Hospital, in line with the CCG’s Patient Experience Strategy.

Patient electronic records

Nationally, Ramsay will introduce a new patient records software package in 2017 which is a comprehensive electronic patient records system. It will simplify theatre recording processes, consolidate patient information and provide a direct booking capability for our insured patients. We will also be piloting the integration of voice recognition and integration of medical devices (e.g. blood pressure monitors) into the recording software; if successful these capabilities will allow us to reduce our dependence on the use of paper-based patient records and improve service, for example enabling the provision of SMS (text) reminders, self-registration kiosks for patients and electronic prescribing.

CQUINS 2016/17

There are 5 National Indicators, 2 have been rolled over from last year and 3 new schemes have been introduced for 2016/17. NHS England have decided that the National CQUINs are not applicable to Independent Providers

1. NEW: Improving the health & wellbeing of NHS staff. Goal: To improve the support available to NHS staff to help promote their health and wellbeing in order for them to remain healthy and well.

2. NEW: Cancer 62 day waits.


Goal: Patients to receive first definitive treatment within 62 days of an urgent GP referral for suspected cancer and those waiting longer than 62 days are appropriately reviewed and managed.

NEW: Antimicrobial resistance. Goal: Reduction in antibiotic consumption and encouraging focus on antimicrobial stewardship and ensuring antibiotic review within 72 hours.

3. Identification and early treatment of sepsis.Goal: Systematic screening for Sepsis of appropriate patients and where sepsis is identified, to provide timely and appropriate treatment and review.

4. Physical Health of people with Serious Mental illness (SMI).Goal: Service users with SMI have comprehensive cardio metabolic risk assessments, necessary treatments and the results are recorded and shared with the patient and clinical teams.

The national CQUINs were not applicable to Ramsay hospitals for 2016/17 and therefore the 2.5% will be made up entirely of locally agreed CQUIN schemes.

Local CQUINS

To develop and implement a Patient Experience strategy

The CQUIN is carried forward from 2015/16 and will develop and begin implementation of a patient experience strategy for NHS patients. The strategy will address the following points:

Gathering feedback from patients through questionnaires

How to engage and communicate with patients to make improvements ( e.g. Patient participation, patients on walk-arounds)

How to collate feedback from incidents, complaints, compliments.

Systems to implement actions and feedback improvements made to the patients.

To display patient feedback in waiting areas etc.

Any other patient experience related work the provider wishes to address.


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.

2.2.1 Review of Services

During 2015/16 Oaklands Hospital provided seven NHS services and has reviewed the data available to them on the quality of care in all of these NHS services.

The income generated by NHS services reviewed in 1st April 2015 to 31st March 2016 represents 100% per cent of the total income generated from the provision of NHS services by Oaklands Hospital for 1st April 2015 to 31st March 2016

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 hospital’s senior managers together with regional and corporate Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other Ramsay hospitals and identifying key areas for improvement.

In the period for 2015/16, the indicators on the scorecard which affect patient safety and quality were:

Human Resources

Staff Cost % Net Revenue 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

Patient

Formal Complaints per 1000 HPD's

Patient Satisfaction Score Significant Clinical Events per

1000 Admissions Readmission per 1000

Admissions

Quality

Workplace Health & Safety Score

Infection Control Audit Score

2.2.2 Participation In Clinical Audit


During 1st April 2015 to 31st March 2016, Oaklands Hospital participated in two national clinical audits which it was eligible to participate in.

The national clinical audits and national confidential enquiries that Oaklands Hospital participated in, and for which data collection was completed during 1st April 2014 to 31st 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.

Name of audit / Clinical OutcomeReview Programme

National Joint Registry (NJR)

Elective surgery (National PROMs Programme)

The reports of national clinical audits from 1st April 2015 to 31st March 2016 were reviewed by the hospital’s Clinical Governance Committee.

Local Audits

The reports of local clinical audits from 1st April 2015 to 31st March 2016 (schedule attached in Appendix 2) were reviewed by the hospital’s Clinical Governance Committee.

2.2.3 Participation in Research

There were no patients recruited during 2015/16 to participate in research.

2.2.4 Goals agreed with our Commissioners using CQUINs

A proportion of Oaklands Hospital’s income from 1 April 2015 to 31st March 2016 was conditional on successfully achieving Commissioning for Quality and Innovation payment framework

2.2.5 Statements from the Care Quality Commission (CQC)

Oaklands Hospital is required to register with the Care Quality Commission and its current registration status on 4th March 2015 is registered without conditions.


Oaklands Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.

2.2.6 Data Quality

NHS Number and General Medical Practice Code Validity

The Ramsay Group submitted records during 2015/16 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included:

The patient’s valid NHS number: 99.96% for admitted patient care; 99.96% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals).

The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; andAccident 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 2015/16 was 85% and was graded ‘green’ (satisfactory).

This information is publicly available on the DH Information Governance Toolkit website at:https://www.igt.hscic.gov.uk

Clinical Coding Error Rate

Oaklands Hospital was subject to the Payment by Results clinical coding audit during 2015/16 by the National Audit Commission, the result of which is shown below.


https://www.igt.hscic.gov.uk/

Hospital Site Audit Date

Next Audit Date

Primary Diagnosis

Secondary Diagnosis

Primary Procedure

Secondary Procedure

Oaklands Hospital June 2016 June 2018 100% 96.1% 98.3% 100%

The Hospital continues to take the following actions to improve data quality:

Regular training to ensure staff understand importance of accurate data input and have sufficient technical competence

Employment of clinical coder to improve accuracy of recording Supporting national projects to ensure data accuracy

2.2.7 Stakeholders’ Views on Oaklands Hospital’s Quality Account 2015/16

A copy of the Quality Account has also been sent to Health watch

Feedback from the Hospital’s lead Clinical Commissioning Group is as follows:-

“NHS Salford Clinical Commissioning Group (CCG) welcomes the opportunity to comment on the 2015/16 Oaklands Hospital. We work closely with the Hospital during the year reviewing a range of indicators in relation to quality, safety and performance; gaining assurance of the delivery of safe and effective services. We are pleased to confirm that the material presented within the Quality Account is consistent with information supplied to the commissioners throughout the year. Salford CCG have worked closely with Oaklands Hospital in light of the recent expansion to the theatres where members of the CCG Quality Team have undertaken a number of walk arounds during the year and have monitored the implementation of new and more efficient pathways for patients through the CQUIN scheme. Feedback has been encouraging in terms of patient experience, strong communication, the values and behaviour of staff and their commitment to patient safety.

We welcome the continued focus on making improvements to the Patient Experience strategies at Oaklands and look forward to conducting a more collaborative approach to meeting the patients’ needs and gathering their views. Commissioners are keen to review the evidence that is provided as part of the patient experience CQUIN.

The CCG are encouraged by the creation and submission of a quarterly summary report and recognise the work that goes into this report in order to provide assurance. This report shows that incidents are investigated and lessons learned are implemented following incidents or complaints.


We acknowledge the focus on improving safety within the organisation as evidenced through the use of the surgical safety checklist, the use of VTE assessments and data collection for the safety thermometer. The CCG welcomes the hospital’s continued commitment to this important area.

The information outlined in relation to participation in national and local audits and provides evidence that the organisation is committed to benchmarking and monitoring performance against agreed standards. It would be helpful to see evidence of how the result of this work has translated into improved outcomes for people using services in future reports.”

Part 3: Review of quality performance 2015/2016Statement from Vivienne Heckford

“This publication marks the fifth successive year since the first edition of Ramsay Quality Accounts. Through each year, month on month, we analyse our performance on many levels, we reflect on the valuable feedback we receive from our patients about the outcomes of their treatment and also reflect on professional opinion received from our doctors, our clinical staff, regulators and commissioners. We listen where concerns or suggestions have been raised and, in this account, we have set out our track record as well as our plan for more improvements in the coming year. This is a discipline we vigorously support, always driving this cycle of continuous improvement in our hospitals and addressing public concern about standards in healthcare, be these about our commitments to providing compassionate patient care, assurance about patient privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open and honest where outcomes and experience fail to meet patient expectation so we take action, learn, improve and implement the change and deliver great care and optimum experience for our patients.”

Vivienne Heckford, Director of Clinical ServicesRamsay Health Care UK

Ramsay Clinical Governance Framework 2016


The aim of clinical governance is to ensure that Ramsay develops ways of working which assure that the quality of patient care is central to 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


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.


3.1The Core Quality Account Indicators The following tables and graphs show comparisons regarding key data between the following:

The best scoring hospital for this quality indicator based on all England hospitals providing NHS services

The worst scoring hospital for this quality indicator based on all England hospitals providing NHS services

The average score for this quality indicator Oaklands Hospital

Mortality Rates

The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality at Trust level across the NHS in England.

Period Best Worst Average Period OaklandsOct 13-Sep

14 RKE 0.597 RPA 1.20 Eng 1 2013/14 NVC12 0

Oct 14-Sep 15 RJ1 0.737 RVW 1.18 Eng 1 2014/15 NVC12 0

Readmissions

This measures the percentage of surgical patients being admitted to Hospital following treatment and does not include emergency readmissions

National Readmissions:

Period Best Worst Average2010/11 Multiple 0.0 5P5 22.76 Eng 11.432011/12 Multiple 0.0 5NL 41.65 Eng 11.45

Oaklands Hospital Readmissions:

Period Oaklands2010/11 NVC12 11.142011/12 NVC12 7.8


VTE assessment

This measures the provider’s compliance with recording information on admitted adults who have risk assessed for Venous Thromboembolism

National VTE assessment:

Period Best Worst Average15/16 Q2 Several 100% RWA 75.0% Eng 95.9%15/16 Q3 Several 100% RWW 61.5% Eng 95.6%

Oaklands Hospital:

Period Oaklands15/16 Q2 NVC12 97.9%15/16 Q3 NVC12 97.5%

C Difficile rate

This measures the incidence of this infection per 100,000 bed days

National C Difficile rate:

Period Best Worst Average2013/14 Several 0 RMP 32.5 Eng 14.7

Oaklands Hospital:

Period Oaklands

2012/13 NVC12 0.0

2013/14 NVC12 0.0


Serious Untoward Incidents

This measures incidence of severe/death patient safety incidents per 1000 admissions (Oct13- Mar14) and per 1000 bed days (Apr-Sep14)

National SUI’s Severity level 1

Period Best Worst AverageApr 14 - Sep

14 Several 0 RP5 22.04 Eng 0.15

Oct 14 - Mar 15 RD3 0.021 RJC 1.53 Eng 0.18

Oaklands Hospital

Period OaklandsApr 14 - Sep

14 NVC12 0.00

Oct 14 - Mar 15 NVC12 0.00

Friends and Family Test

This measures the percentage of patients that would recommend the Hospital

National:

Period Best Worst AverageJan-15 Several 100% RCUEF 72.7% Eng 95.7%Feb-16 Several 100% RCUEF 74.2% Eng 95.7%

Oaklands Hospital :

Period OaklandsJan-16 NVC12 N/AFeb-16 NVC12 90.2%

Responsiveness to Personal Needs


There is no data available to Oaklands Hospital or independent sector hospitals by the Health and Social Care Information Centre with regard to the hospitals responsiveness to the personal needs of its patients during the reporting period 2015/16

Oaklands considers that the data in the graph below reflects the fact that our patients tell us on the whole, we provide a service that is more responsive to their needs we compared to the national average for all providers in England. The most up to date data available is from 2013/14

The percentage measure is taken from the national NHS patient satisfaction survey

National:

Period Best Worst Average2012/13 RPC 88.2 RJ6 68.0 Eng 76.52013/14 RPY 87.0 RJ6 67.1 Eng 76.9

Oaklands Hospital:

Period Oaklands2013/14 NVC12 92.22014/15 NVC12 89.9

Patient Reported Outcome Measures

Table 1: Pre-operative participation and linkage

Eligible hospital

procedures

Pre-operative questionnaires

completedParticipation

RatePre-operative

questionnaires linked

Linkage Rate

All Procedures 396 440 111.1% 367 83.4%

Groin Hernia 79 76 96.2% 68 89.5%

Hip Replacement 96 96 100.0% 86 89.6%

Knee Replacement 221 268 121.3% 213 79.5%

Varicose Vein 0 0 0.0% 0 0.0%


Table 2: Post-operative issue and return

Pre-operative questionnaires

completed

Post-operative

questionnaires sent out

Issue RatePost-

operative questionnaire

s returned

Response Rate

All Procedures 440 434 98.6% 258 59.4%

Groin Hernia 76 75 98.7% 34 45.3%

Hip Replacement 96 94 97.9% 55 58.5%

Knee Replacement 268 265 98.9% 169 63.8%

Varicose Vein 0 0 0.0% 0 0.0%

Hernia repair

National PROMs:

Period Best Worst AverageApr14 - Mar15 RD3 0.154 R1H 0.027 Eng 0.084

Apr15 – Sep15 RJL 0.135 RR7 0.008 Eng 0.088

Oaklands Hospital:

Period OaklandsApril 14-Mar15 NVC12 0. 105April 15-Sept 15 NVC12 *

*Volumes too low to report

Varicose Veins

National PROMs:

Period Best Worst AverageApr14 - Mar15 R1K 5.59 RTE -14.455 Eng -8.252

Apr15 - Sep15 RK5 -4.265 RM1 -13.139 Eng -8.989


Oakland Hospital PROMs:

Period OaklandsApr14 - Mar15 NVC05 *

Apr15 - Sep15 NVC05 *

*Varicose vein surgery is currently no longer offered at Oaklands Hospital

(Primary Hips) Hip Replacement

National PROMs

Period Best Worst AverageApr14 - Mar15 NTE02 24.652 RQX 16.292 Eng 21.443

Apr15 - Sep15 NVC04 24.667 RJL 18.13 Eng 22.088

Oaklands Hospital PROMs:

Period OaklandsApr14 - Mar15 NVC12 20.604

Apr15 - Sep 15 NVC12 *


Knee Replacement (Primary knees)

National PROMs:

Period Best Worst AverageApr14 - Mar15 NT438 19.492 RE9 11.475 Eng 16.148

Apr15 - Sep15 RVV 19.339 RK5 12.403 Eng 16.794


Oaklands Hospital

Period OaklandsApr13- Mar

14 NVC12 13.908

Apr15 - Sep15 NVC12 *


3.2 Patient safety

We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety.

Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators.

Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below.

3.2.1 Infection prevention and control

Oaklands Hospital has had no reported MRSA Bacteraemia in the reporting period.

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:

The dedicated Infection Prevention and Control link nurse provides mandatory training in hand hygiene to all staff and completes a hand hygiene training session during the staff induction day for all new staff.

Hand hygiene awareness days are led by the infection control link nurse involving staff, patients and visitors and information in waiting areas.

The infection control nurse reviews and completes a root cause analysis of confirmed infections to determine any possible trends with results being presented at our quarterly infection control committee meetings. We continue to have a robust process in identifying and reporting of all infections with a dedicated infection control nurse in post. As can be seen in the graph below our infection rate has decreased over the last year and rates remain below the national average.

2013/14 2014/15 2015/160

0.05

0.1

0.15

0.2

0.25

0.3

Infection Rates

Oaklands Hospital

Infe

ction

Rat

es

(per

cent

age

of A

dmiss

iosn

s)

3.2.2 Cleanliness and Hospital Hygiene

Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE).

PLACE assessments occur annually at Oaklands Hospital, providing us with a patient’s eye view of the buildings and facilities, giving us a clear picture of how the people who use our hospital see it and how it can be improved.

The Hospital scored 89.09% for the four areas of cleanliness, food, privacy and the condition of facility during the period. An action plan was compiled and managed by


senior management to ensure feedback was acted upon and facilities remain of a high standard.

Nationally, the main findings are as (please see additional note below*), followed by FHH scores;

The National Average for Cleanliness was 97.57% , OH 100%

The National Average for Food and Hydration was 88.49% , OH 71.65%

The National Average for Privacy Dignity and Wellbeing was 86%; OH 90.48%

The National Average for Condition Appearance and Maintenance was 90.11% , OH 94.26%


`3.2.3 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.

In addition, there has been and continues to be, a focus on the use of safety sharps within clinical departments. Compliance with the use of safety sharps is good, and where non safety sharps are in use, risk assessments are in place to support this practice.

3.3 Clinical effectiveness

Oaklands Hospital 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 Hospital Medical Advisory committee to ensure results are visible and tied into actions required by the organisation as a whole.

3.3.1 Return to theatre

Ramsay is treating significantly higher numbers of patients every year as our services grow. The majority of our patients undergo planned surgical procedures and so monitoring numbers of patients that require a return to theatre for supplementary treatment is an important measure. Every surgical intervention carries a risk of complication so some incidence of returns to theatre is normal. The value of the measurement is to detect trends that emerge in relation to a specific operation or specific surgical team. Ramsay’s rate of return is very low consistent with our track record of successful clinical outcomes.


2013/14 2014/15 2015/160

0.020.040.060.08

0.10.120.140.160.18

0.2

Return to Theatre Score

Oaklands Hospital

Retr

nn to

The

atre

(Per

cent

age

of A

dmiss

iosn

s)

Oaklands Hospital continues to have a very low return to theatre rate as a percentage of overall admissions

3.3.2 Readmissions

13/14 14/15 15/160.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

Readmissions

Oaklands Hospital Linear (Oaklands Hospital)

Rate per 100 discharges


3.3.3 Transfers

13/14 14/15 15/160.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

Transfers



3.3.4 Serious Untoward Incidents

13/14 14/15 15/160.00%

0.05%

0.10%

0.15%

0.20%

0.25%

SUIs



3.3.5 Falls


13/14 14/15 15/160.00%

0.05%

0.10%

0.15%

0.20%

0.25%

Falls



3.3.6 All Incidents

13/14 14/15 15/160.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%

All Incidents



3.4 Patient experience


13/14 14/15 15/160.00%

0.01%

0.02%

0.03%

Serious Complaints



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 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 standard agenda items on the Hospital Management meeting under Customer Service, Local Governance Committee for discussion around lessons learnt, and department team meetings to review feedback, discuss trend analysis and implement 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/emails PROMs surveys Care pathways – patient are encouraged to read and participate in their plan of

careAs a result of patient feedback, changes we have made include:

Patients who stay overnight are now admitted directly to the inpatient ward to allow them to have a better settling in period and become familiar with their surroundings and the Clinical staff who would be caring for them post operatively. Due to the increased activity at Oaklands following the development of Theatre 3 this has also allowed a more efficient patient journey for those admitted as a day case within the Surgical Admissions Unit.

Patient information delivered at Pre-Operative clinic has been improved to include information regarding relatives visiting hours and that the Hospital and grounds are non- smoking.

3.3.1 Patient Satisfaction SurveysOur patient satisfaction surveys are managed by a third party company called ‘Qa Research’. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient’s views.

Every patient is asked if they consent to receive an electronic survey or phone call to take part in this survey. 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 1 week of receiving them so that a response can be made to the patient as soon as possible.

2014/15 2015/160

20

40

60

80

100

88.1 85.1

Satisfaction ScoresNHS/Private Patients

Oaklands Hospital

Satis

facti

on S

core

s

Patient Feedback (Received via Friends & Family March 2016)


“Staff are amazing”

“Extremely likely excellent staff and very clean hospital”

“Put my mind at rest”

“Well looked after”

“Was made to feel at ease”

“Exceptional care”

“Staff were so good”

“Everybody has been friendly and helpful. Thank you”

“Excellent treatment”

“Staff outstanding”

“Staff very professional and friendly”

“They were very understanding of my nervousness”


Appendix 1

Services covered by this Quality AccountServices Provided Peoples Needs Met for:

Treatment of Disease, Disorder

Or injury

Cosmetics, Dermatology, Ear, Nose and Throat (ENT), General surgery, Gynaecological, General medicine, Ophthalmic, Orthopaedic, Physiotherapy, Rheumatology, Sports medicine, Urology

All patients 16 years and over

0-16 years Consultation only

Surgical

Procedures

Breast surgery, Cosmetics, Day and Inpatient Surgery, Dermatology, Ear, Nose and Throat (ENT), General surgery, Gynaecological, Ophthalmic, Oral maxillofacial surgery, Orthopaedic, Urology

All patients 16 yrs and over excluding:

Patients with blood disorders (haemophilia, sickle cell, thalassaemia)

Patients on renal dialysis Patients with history of malignant hyperpyrexia Planned surgery patients with positive MRSA screen are

deferred until negative Patients who are likely to need ventilatory support post

operatively Patients who are above a stable ASA 3. Any patient who will require planned admission to ITU post

surgery Dyspnoea grade 3/4 (marked dyspnoea on mild exertion

e.g. from kitchen to bathroom or dyspnoea at rest) Poorly controlled asthma (needing oral steroids or has had

frequent hospital admissions within last 3 months) MI in last 6 months Angina classification 3/4 (limitations on normal activity

e.g. 1 flight of stairs or angina at rest) CVA in last 6 months

However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment.

16 years and above

Diagnostic and

screening

Imaging services, Phlebotomy, Urinary Screening and Specimen collection.

All adults 18 yrs and over

Children Zero years – 16 ( non invasive procedures only)


Appendix 2 – Clinical Audit Programme 2015/16.


Oaklands 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:

Telephone: 0161 787 7700

www.oaklands-hospital.co.uk


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