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Oaklands Hospital

Quality Account 2013/14

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 2013/14 (looking back)

2.1.2 Clinical Priorities for 2014/15 (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 2013/14 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account Indicators

3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

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.

“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high quality patient care is our number one goal. This relies not only on excellent medical and clinical leadership in our hospitals but also upon an organisation-wide commitment to drive year on year improvement in patient satisfaction and clinical outcomes.

Delivering clinical excellence depends on everyone in the organisation. It is not about reliance on one person or a small group of people to be responsible and accountable for our performance. It is essential that we establish an organisational culture that puts the patient at the centre of everything we do and as a long standing and major provider of healthcare services across the world, Ramsay has a very strong track record as a safe and responsible healthcare provider and we are proud to share our results.

Across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends. We value our people and with every year we set our targets higher, working on every aspect of our service to bring a continuing stream of improvements into our facilities and services.”

(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)

Quality Accounts 2013/14 of 35

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. 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 fourth 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

Stefan Andrejczuk, 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 currently has 15 single rooms all with en- suite facilities and a six bedded, dedicated day case facility.

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, Ophthalmics 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 Quality Priorities for 2014/2015On an annual cycle, Oaklands Hospital develops an operational plan to set objectives for the year ahead.

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

To meet these aims, we have various initiatives ongoing at any one time. The priorities are determined by the hospital’s Senior Management Team taking into account patient feedback, audit results, national guidance and the recommendations from various hospital committees which represent all professional and management levels.

Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.

2.1.1 A review of clinical priorities 2013/14 (looking back)

Surgical Safety Checklist - 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.

VTE Assessment – There has been continued compliance with completion of VTE documentation for patients where appropriate. Support from Ramsay’s Group Medical Director included a presentation to the Medical Advisory Committee on clinician responsibilities in the completion of VTE risk assessments. Quarterly audit scores have demonstrated that compliance remains a focus across the whole of the Ramsay Group.

Infection Control – We have had no reportable infections and no outbreaks reported in the period. We continue to screen patients for MRSA where appropriate in line with NHS England guidelines and training for staff on hand hygiene is mandatory. The infection control team have worked to improve standards in environmental cleaning in the period with the Clinical Lead leading quarterly environmental audits in the period.


Internal audits demonstrate that compliance remains high, achieving between 97% and 100% in the period.

PLACE (Patient led assessment of the care environment) – The first PLACE assessment was carried out in the year, with patient representatives performing the assessment with members of Oaklands Hospital management, scoring an average of % for the four areas of cleanliness, food, privacy and the condition of facility. The current scoring system of recording NA (Not Applicable) for some sections under Privacy and Dignity are under review as this gives a negative score.

Incident Reporting – The Ramsay Group risk management system ‘RiskMan’ is used to report clinical incidents, health and safety incidents, staff wellbeing and absence together with patient feedback. Additional training has been given to all staff to ensure timely, comprehensive and effective reporting and compliance with reporting has been good. There has been one serious untoward incident reported in the period. This was investigated and identified as a recognised complication of surgery.

Competency Training – Competency assessment tools have been completed for all clinical staff appropriate to their area of practice.

Preoperative Assessment – The preoperative assessment policy is followed and provides safe and efficient assessment of all patients following their outpatient clinic appointment. Patients complete a medical questionnaire which is reviewed by nursing staff to determine the level of preoperative assessment required to ensure the appropriate needs of the patient are met.

Patient Satisfaction Survey – The web based satisfaction survey has been in place since February 2013 and response rates have gradually increased over the period with a response rate of 45.7% at the end of March 2014. The overall satisfaction rate for the year was 90.5%.

Patient Reported Outcome Measures Studies (PROMS) – the hospital has encouraged patients to participate in PROMs surveys to monitor patient assessed outcomes of surgery regarding varicose veins, hip and knee replacement and inguinal hernia.

Information Security – Oaklands Hospital has achieved the information security accreditation ISO 27001. The process of raising the importance of data protection and information security has been successful and fully embraced by our staff.


Clinical Documentation Audits - Remain a priority in all areas with a corporate Ramsay focus set for 2014/15 on theatre safety checks and physiotherapy documentation checks.

Local CQUINS

Patient Shared Decision Making – this continued for THR patients as per last year and TKR and Carpel tunnel release were added.

Care Planning Protocol – care pathways for Laparoscopic Cholecystectomy and Scarf Osteotomy were reviewed and implemented from 1st April 2014.

Use of Digital Technology – work continues with the IT teams at the CCG and SRFT to enable the installation of Docman.

National CQUINS

Friends and Family Test – The hospital undertook Friends & Family testing with both inpatient and day case patients in the period, achieving a 42% response rate with a 100% rate for ‘Extremely Likely to Recommend’ from Inpatients and 98% of day cases reporting a “ Likely or Extremely Likely to Recommend”.

VTE risk assessment – The hospital was set a compliance target of 95%, the national target being 95%, and continuously achieved this reaching 100% compliance in April 2014.

Safety Thermometer- continued to submit to NST on a monthly basis with no adverse events reported.

Advancing Quality- this initiative is aimed at improving the quality of care and patient experience. In 2014 Oaklands Hospital was recognized with an award for best performing trust participating in one clinical focus area.

2.1.2 Clinical Priorities for 2014/15 (looking forward)

Patient Safety

Surgical Safety Checklist - Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented as standard practice. Monthly audits will continue to be


undertaken with an expectation of 100% compliance; where this is not achieved actions plans will be developed and responsibilities communicated with the teams. Briefing and debriefing sessions after all operating sessions continue and give opportunity for shared learning, recommendations for future practice and aim to encourage autonomy for all members of the team. Compliance will be monitored by regular audit and reviewed by the hospital’s Clinical Governance and Medical Advisory Committees.

NHS Safety Thermometer - The NHS Safety Thermometer is a national CQUIN to measure, monitor and analyse patient harms and ensure 'harm free' care. Oaklands Hospital has been 100% compliant with data submission and will continue to submit this data in relation to pressure ulcers, falls and urinary tract infections in those with a catheter.

VTE Assessment - A VTE risk assessment is completed for patients according to CM 001 VTE policy and requires consultants to review and complete a written assessment prior to procedure. This remains a focus at Oaklands Hospital with quarterly audits completed to maintain standards. Results are reviewed and actions determined at both the hospital’s Clinical Governance and Medical Advisory Committees.

Staffing – To ensure adequate numbers of skilled staff are available to care for our patients staff rosters are prepared in advance. An electronic rostering tool ‘Allocate’ was introduced in December 2013 taking into account the necessary skill mix for scheduled patient activity.

The Ramsay Academy provides learning and development opportunities for all staff and the Management Development Framework provides opportunities for our leaders to develop skills and knowledge. We recognise the value of the Health Care Assistant (HCA) within Ramsay and competency assessments are in place to allow all HCAs to reach their full potential. Acknowledging the Cavendish review we are adopting the ‘productive team’ model ensuring ‘a holistic approach to care, focused on ensuring the best possible outcomes for the patient, staff and the organisation’. We promote a culture of support and mentoring in developing our existing staff and will be introducing apprenticeships across different job roles in the next year.

Clinical Effectiveness

Maintaining Endoscopy Standards – Oaklands Hospital will be working towards successful JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation in 2015; biannual submission to GRS (Global Rating Score) continues. This tool enables us to assess how well we provide a patient-centred service, demonstrating compliance against the four domains:


clinical quality quality of patient experience workforce training

Patient Experience – informing patient choice

Patient Satisfaction Survey – We will continue to encourage patients to provide feedback using our web based satisfaction survey. ‘Hot alerts’ received following completion of the survey will be reviewed by the hospital’s General Manger and Matron and action taken where there are areas identified for improvement. All comments positive and negative are shared with the whole team along with a monthly patient satisfaction dashboard. Compliments and complaints are reviewed at the hospital’s Clinical Governance and Medical Advisory Committees and lessons shared with the hospital’s departments. We will also continue to monitor posts on NHS Choices. We have added to current patient feedback mechanisms by including patients in hospital PLACE audits.

Friends and Family Test - The Friends and Family Test has been extended to include Outpatients from April 2014. Patients will be invited to complete a paper or electronic questionnaire following their visit to the hospital. Results from this survey will be reviewed and shared with the hospital’s departments.

Patient Reported Outcome Measures Studies (PROMS) – This is a national indicator providing important information regarding the effectiveness of surgery as perceived by the patient. We will continue to monitor patient response rates. The consultant surgeons will continue to ensure patients are fully informed and invited to take part in the survey by completing a questionnaire prior to their surgery.

Advancing Quality – Aimed at improving quality of care and patient experience is a local CQUIN where Oaklands Hospital submits data regarding DVT and antibiotic prophylaxis. Compliance with the best practice pathway is monitored via internal submission of data onto the Clarity database and externally audit of patient records.

Equality Delivery System – Oaklands Hospital will be one of the first private hospitals to work on NHS England’s EDS2 initiative to ensure that the services we provide for patients and that the working environment we provide to staff is free of discrimination, in accordance with the nine protected characteristics under the Equality Act 2010; age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, gender and sexual orientation.


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 2013/14 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 2013 to 31st March 2014 represents 100% per cent of the total income generated from the provision of NHS services by Oaklands Hospital for 1st April 2013 to 31st March 2014.

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 2013/14, 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 Consultant Satisfaction Score

2.2.2 Participation In Clinical Audit


During 1st April 2013 to 31st March 2014, Oaklands Hospital participated in three 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 2013 to 31st March 2014, 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

% cases submitted

National Joint Registry (NJR) 100%

Elective surgery (National PROMs Programme) 63%

Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death

0% - no deaths in period.

PROMs for elective surgery figure of 63% was affected by no national code for the prosthesis used in computer aided surgery. This has now been rectified.

The reports of national clinical audits from 1st April 2013 to 31st March 2014 were reviewed by the hospital’s Clinical Governance Committee.

Local Audits

The reports of local clinical audits from 1st April 2013 to 31st March 2014 (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 2013/14 to participate in research.


2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework

A proportion of Oaklands Hospital’s income from 1 April 2013 to 31st March 2014 was conditional on achieving quality improvement and innovation goals through the 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 31st March 2014 is registered without conditions.

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


2.2.6 Data Quality

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

NHS Number and General Medical Practice Code Validity

Oaklands Hospital submitted records during 2013/14 to the SecondaryUses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included:

The patient’s valid NHS number:

99.97% for admitted patient care; 99.96 for outpatient care; and 0% for accident and emergency care (not undertaken at our

hospital).

The General Medical Practice Code:

100% for admitted patient care; 100% for outpatient care; and 0% for accident and emergency care (not undertaken at our

hospital).

Information Governance Toolkit Attainment Levels

Ramsay Group Information Governance Assessment Report scored 83% for 2013/14, and was graded ‘green’ (satisfactory).

Clinical Coding Error Rate

Oaklands Hospital was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission.


2.2.7 Stakeholders’ Views on Oaklands Hospital’s Quality Account 2013/14

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

We have been working closely with the hospital during the year, gaining assurance of the delivery of safe and effective services. Their quality and performance is monitored through regular contracts meetings where data is reviewed and discussed. We are pleased to see that the information presented within the Quality Accounts is consistent with information supplied to the commissioners throughout the year. The CCG recognises the commitment of the Oaklands to quality improvement in achieving the CQUIN targets set for the year.

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 emphasis on listening to patients about their experience of using services is evident in the information presented and we are pleased to see the initiatives outlined on how this area is being developed. Positive feedback by patients is demonstrated in the levels of satisfaction outlined in the patient survey results. It would be useful to see this information triangulated with data on the numbers of complaints including any themes or trends along with actions taken as a result of any such negative feedback in the Quality Accounts for 2014/15 Participation of patient representatives in the assessment of the environment through the PLACE assessments demonstrates the organisation’s commitment to patient engagement. This is further evidenced by encouraging the involvement of patients in their care in terms of participating in care plans and the use of patient CCG Draft response to Oaklands Quality Accounts

NHS Salford Clinical Commissioning Group (CCG) welcomes the opportunity to reported outcome measures (PROMs). Whilst the return rate on PROMs is outlined within the accounts it would be helpful to see some comparative data presented in relation to the content of these outcomes in future reports.

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.

We will continue to work in collaboration with the hospital in driving forwards further changes and improvement over the coming year; through our regular contracts and performance meetings

Francine Thorpe


Head of Quality & Innovation

Part 3: Review of quality performance 2013/2014

Statements of Quality Delivery – Rhona Davis, Matron Oaklands Hospital

Introduction

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

(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)

Ramsay Clinical Governance Framework 2014

The aim of clinical governance is to ensure that Ramsay 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.


3.1 The Core Quality Account Indicators

National Mortality Rates

Period Best Worst Average2012/13 RKE 0.65 RXL 1.17 Eng 12013/14 RKE 0.63 RBT 1.15 Eng 1

Oaklands Mortality Rates

Period Oaklands2012/13 NVC12 02013/14 NVC12 0

National Expected Deaths

Period Best Worst AverageApr12 - Mar13 RBA 0.1 RWH 44.0 Eng 20.4Jul12 - Jun13 RBA 0.0 RWH 44.1 Eng 20.2

Oaklands Expected Deaths

Period Oaklands2012/13 NVC12 0.02013/14 NVC12 0.0


PROMs

Oaklands Hospital has taken action to improve the returns rate of PROMs questionnaires and so the quality of its services, by actively involving consultants in the PROMs process in encouraging patient participation.

National PROMs (Hernia)

Period Best Worst AverageApr12 - Mar13 NT415 0.157 NVC27 0.015 Eng 0.085Apr13 - Sep13 RTG 0.138 RNA 0.019 Eng 0.086

Oaklands PROMs (Hernia)

Period OaklandsApr12 - Mar13 NVC12 *Apr13 - Sep13 NVC12 *

National PROMs (Veins)

Period Best Worst AverageApr12 - Mar13 RV8 5.14 NT350 -15.92 Eng -8.374Apr13 - Sep13 RTD -9.74 RLN -10.52 Eng -9.46

Oaklands PROMs (Veins)

Period OaklandsApr12 - Mar13 NVC12 * Apr13 - Sep13 NVC12 *

National PROMs (Hips)

Period Best Worst AverageApr12 - Mar13 NT209 24.68 RKE 17.21 Eng 21.32Apr13 - Sep13 NT318 25.44 RHQ 18.34 Eng 21.61


Oaklands PROMs (Hips)

Period OaklandsApr12 - Mar13 NVC12 *Apr13 - Sep13 NVC12 *

National PROMs (Knees)

Period Best Worst AverageApr12 - Mar13 NT219 20.37 RAP 12.46 Eng 16.01Apr13 - Sep13 RDE 20.09 RM1 14.32 Eng 16.74

Oaklands PROMs (Knees)

Period OaklandsApr12 - Mar13 NVC12 14.901Apr13 - Sep13 NVC12 *

* Volumes were too low to be reported.

National Readmissions

Period Best Worst Average2010/11 RF4 0.0 RYR 15.8 Eng 11.042011/12 RF4 0.0 RYR 15.8 Eng 11.08

Oaklands Readmissions



National VTE Assessment

Period Best Worst Average13/14 Q3 Several 100% NT244 63.2% Eng 95.8%13/14 Q4 Several 100% NT205 67.0% Eng 96.0%

Oaklands VTE Assessment

Period Oaklands13/14 Q3 NVC12 99.9%13/14 Q4 NVC12 96.9%

National C-Difficile Rate

Period Best Worst Average2012/13 Several 0 RNA 58.2 Eng 22.22013/14 Several 0 RVW 30.8 Eng 17.3

Oaklands C-Difficile Rate


National Patient Safety Incident Rate

Period Best Worst Average2011/12 RP6 2.6 TAJ 84.4 Eng 13.52012/13 RRF 2.0 RAT 85.6 Eng 14.8

Oaklands Patient Safety Incident Rate



National SUIs (Severity Level 1)

Period Best Worst AverageJul - Sep 12 NA NA NA

Oct11 - Sep12 NA NA Eng 11,563

Oaklands SUIs (Severity Level 1)

Period Oaklands2012/13 NVC12 0.0%2013/14 NVC12 0.0%

National Friends and Family Test

Period Best Worst AverageJan-14 Several 100 RPA02 27 Eng 73Feb-14 Several 100 RPA02 18 Eng 73

Oaklands Friends and Family Test

Period Oaklands2012/13 NVC12 1002013/14 NVC12 100


3.2 Patient Safety

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

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

3.2.1 Infection Prevention and Control

Oaklands Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 5 years.

We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents year on year.

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 infection control link nurse has provided 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.

Observational hand hygiene audits were undertaken by the infection control link nurse resulting in additional gel dispensers being placed in the unit.

Our infection control rate remains very low and our reporting and investigating of potential infections has improved in the last year. Any patient presenting signs of an infection is reviewed by the infection control link nurse and a root cause analysis


completed to determine any possible trends, results are presented at our quarterly infection control committee meetings. There have not been any trends identified in the period.

2011/12 2012/13 2013/140

0.05

0.1

0.15

0.2

0.25

Infection Rates

Oaklands Hospital

Infection

Rates

(percentage of Adm

issiosns)

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 87% for the four areas of cleanliness, food, privacy and the condition of facility. The current scoring system is under review as recording NA (not applicable) in the Privacy and Dignity section gives a negative score.

An action plan was compiled and managed by senior management to ensure feedback was acted upon and facilities remain of a high standard.


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 that we keep up to date with all safety issues.

In addition to mandatory training the Health and Safety Coordinator has coordinated sharps awareness programmes throughout the year ensuring the use of sharps-safe devices where these are available. There has also been training on waste management ensuring the correct segregation of waste taking into account the effect on the environment and raising staff awareness on this issue. We have supported a team member to complete a training course to enable them to provide manual handling training to all of our staff.

3.3 Clinical Effectiveness

Oaklands 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.

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.

2011/12 2012/13 2013/140

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Return to Theatre Score

Oaklands Hospital

Retrnn

to The

atre

(Percentage of Adm

issiosns)

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 fed back 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 fed back via the various methods below, and are regular agenda items on the local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and NHS bodies occurs as required and according to Ramsay and NHS England policy.

Feedback regarding the patient’s experience is encouraged in various ways via:

Web based survey with a web based invitation


Hot alerts received within 48hrs of a patient making a comment on their web survey

Friends and Family questionnaire ‘We value your opinion’ leaflet provided to patients on discharge Verbal feedback to Ramsay staff - including Consultants, Matrons and

General Manager whilst visiting patients Written feedback via patient letters and emails PROMs surveys Care pathways – patient are encouraged to read and participate in their plan

of care

3.4.1 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 patients’ views.

Every patient is asked their consent to receive an electronic survey or phone call following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services. Any text comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital Manager within 48hrs of receiving them so that a response can be made to the patient as soon as possible.

2012/13 2013/140

20

4060

80

100120

95.4 89.0

Satisfaction ScoresNHS/Private Patients

Oaklands Hospital

Satisfaction

Scores

We have consistently maintained a high satisfaction rate and proactively seek patient feedback to ensure we maintain this. Please note; a change of satisfaction survey in early 2013 means the year on year data is not comparable.


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 adults 18 yrs and over

Children 3 years and above

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 adults 18 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.


Diagnostic and

screening

Imaging services, Phlebotomy, Urinary Screening and Specimen collection.

All adults 18 yrs and over



Appendix 2 – Clinical Audit Programme 2013/14.


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


oaklands-hospital-qa · web viewthe ramsay health care group, was established in 1964 and has grown...

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