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Euxton Hall 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 2010/11 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account indicators3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

3.5 Case Study

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

Welcome to Ramsay Health Care UK Euxton Hall Hospital is part of the Ramsay Health Care Group

The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals.

We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Group.

“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 38

Introduction to our Quality AccountThis Quality Account is Euxton Hall Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It reports on the period 1st April 2013 to 31st March 2014 and 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 patient’s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on.

Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.


Part 11.1 Statement on quality from the General Manager

“Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As General Manager of Euxton Hall Hospital, I am passionate about ensuring that high quality patient care is our number one priority. This relies not only on excellent medical and clinical delivery but also upon continued commitment to driving improvement in clinical outcomes. Ramsay Health Care UK has a structured clinical governance framework that enables continual review of performance. This allows us to drive improvements for the benefit of all patients

This Quality Account not only accurately documents through our data our achievements in delivering excellent services, but also highlights the areas that we need to improve upon.

Our Quality Account is information for our patients and commissioners to assure them that we are committed to sharing our progressive achievements year on year.”

David Winters

General Manager



1.2 Hospital Accountability Statement

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

David Winters

General Manager


Ramsay Health Care UK

This report has been reviewed and approved by:

Jan Ledward, Chief Officer, NHS Chorley and South Ribble Clinical Commissioning Group

Healthwatch

A copy of the Quality Accounts has been sent to Healthwatch

Dr Ian Drake, Consultant Gastroenterologist, Chairman of Euxton Hall Medical Advisory Committee (MAC),

Mr Stefan Andrejczuk, Regional Director Ramsay Health Care UK,


Welcome to Euxton Hall HospitalEuxton Hall Hospital is one of Lancashire’s leading private hospitals situated on the outskirts of Chorley but close to Preston and Wigan.

The facility offers 32 beds all with en suite facilities to ensure complete privacy. Each room includes a digital television and telephone. Our private patients are automatically allocated a Premium Care single room with en suite facility, they are also provided with Molton Brown toiletries, a newspaper of their choice and an à la carte menu.

The hospital boasts two fully equipped ultra clean air theatres, an endoscopy and small treatment room and by investing in advanced medical technology offers a wide range of treatments and services. Euxton Hall Hospital specialises in orthopaedics procedures offered such as arthroscopy, hip, knee replacement and upper limb surgery and offers rapid access to Breast Care services due to the X-ray and radiology facilities on site.

Euxton Hall Hospital offers the latest physiotherapy support in a purpose built sports injury centre. The hospital has the latest Cybex Isokinetic equipment and offers electrotherapy, continence clinic, back pain clinic, podiatry, personal training, aromatherapy, reflexology and acupuncture.

As well as this we offer

Cardiology Cosmetic Surgery Dermatology Diagnostics ENT Gastroenterology General Surgery Gynaecology Neurology Pain Management Physiotherapy Rheumatology Speech Therapy Urology


With 105 registered Consultants and a workforce of approximately 125 contracted staff and a 24 hour RMO, Euxton Hall Hospital provides fast, convenient, effective and high quality treatment for patients (subject to certain exclusion criteria), whether medically insured, self-pay, or from the NHS.

In addition Euxton Hall Hospital has established a successful outreach clinic, The Gathurst Consulting rooms offering both Gynaecological and General services to the people of Wigan without the need to travel. The hospital is currently investigating the possibility of opening a second outreach clinic.

Each year Euxton Hall Hospital chooses one charity to support for the year and last year it was Hand on Heart – who provides life saving defibrillators to schools. During 2013 enough money was raised to donate one to each of the four local primary schools in Euxton

Part 22.1 Quality priorities for 2013/2014

On an annual cycle, Euxton Hall Hospital develops an operational plan to set objectives for the year ahead.

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

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

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

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

Patient-led Assessments of the Care Environment (PLACE) last year replaced the annual Patient Environment Action Team (PEAT) audit.

PLACE is a patient led audit that will have an assessment team that consists of 50% patients. The audit includes all internal and external areas of the hospital only excluding operating theatres. The audit is divided by each department of the hospital and assesses the standard of cleanliness and general upkeep of the building and grounds. It also evaluates the standard of the food being served to patients, ensuring that all dietary requirements are met. The scoring system employs a system whereby areas are given a ‘Pass’, ‘Fail’ or ‘Qualified Pass’.

Euxton Hall Hospital’s PLACE audit took place on 16th May 2013 and the following is an overview of the scores achieved:

Cleanliness – 92.54% Food – 95.43% Privacy – 90.32% Condition – 84.25%

Clinical Documentation Audits – Remained a priority in all areas with a corporate Ramsay focus In 2013/14 on theatre safety checks and Physiotherapy documentation checks. The team achieved full completion of the Ramsay corporate audit programme.

Surgical Safety Checklist - There have been no ‘Never Events’ at Euxton Hall Hospital in the period and an audit of compliance maintains a key focus with a monthly audit of WHO safety checklists.

VTE Assessment – There has been an improvement in compliance with completion of VTE documentation for patients where appropriate. Support from the 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 an improvement and 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 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.

Incident Reporting – The Ramsay Group risk management system ‘Riskman’ is used to report clinical incidents, health and safety incidents, staff well-being and absence and patient feedback. Additional training has been given to all staff to ensure timely, comprehensive and effective reporting and compliance with reporting has been good.

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 hospital’s web-based satisfaction survey has been in place since February 2013 with a response rate of 46.6% at the end of March 2014. The average satisfaction rate for the year was 94.9%. We have gained a 4.5 star rating on the NHS Choices website following patient feedback posts describing their positive patient experiences.

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. Response rates have improved throughout the year.

Information Security – Euxton Hall 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 has been fully embraced by our staff.

Local CQUINS

Smoking Cessation - The hospital identified and recorded smoking status of all admitted patients and recommended appropriate intervention. The hospital achieved a compliance rate of 100% for 2013/14.

Alcohol Awareness – The hospital identified and recorded alcohol use of all admitted patients and recommended appropriate intervention. The hospital achieved a compliance rate of 100% for 2013/14.


National CQUINS

Friends and Family Test – The hospital undertook Friends & Family testing with both inpatient and daycase patients. In the most recent quarter (Jan/Feb/March 2014) the hospital received an average response rate for daycase patients of 41.3% with an average of 96% rate for ‘extremely likely to recommend’. The average response rate for inpatient patients was 46% with an average of 100% rate for ‘extremely likely to recommend’. The hospital undertook Friends & Family testing with staff in the period, achieving a 51% response rate and a 98% rate for ‘Extremely Likely or likely to recommend’.

VTE Risk Assessment – The hospital was set a compliance target of 97%, for the period compared to the national target of 95%, and continuously achieved 99% or above for the last 12 months.

2.1.2 Clinical Priorities for 2014/15 (looking forward)

Clinical priorities for 2014/15 will focus on: Patient Safety, Clinical Effectiveness, and Patient Experience.

Patient Safety;

The NHS Safety Thermometer focuses on the reduction of patient harm. The power of the NHS Safety Thermometer lies in allowing frontline teams to measure how safe their services are and to deliver improvement locally. This CQUIN requires the hospital to undertake a survey on one day per month, of all appropriate patients, using the NHS Safety Thermometer tool, to collect data on pressure ulcers, falls, new venous thromboembolism (VTE) and urinary tract infection (in patients with a catheter). Euxton Hall has been 100% compliant with data submission and will continue to submit this data.

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.

VTE Assessment - A VTE risk assessment is completed for patients according to CM 001 VTE policy and requires consultants to review and to complete prior to procedure. This remains a focus at Euxton Hall Hospital with quarterly audits completed to maintain standards. Results are reviewed and actions determined at 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 the scheduled patient activity.

In addition, the Ramsay Academy provides learning and development opportunities for all staff and Ramsay’s 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.

Clinical Effectiveness;

The Advancing Quality (AQ) Programme is an innovative quality improvement scheme that aims to improve the quality of healthcare and the patient experience of healthcare across the North West, with the focus for the hospital being hip and knee replacement surgery. Advancing Quality works with clinicians to provide hospitals with a set of quality standards which define and measure good clinical practice. Each measure should be delivered to every patient to ensure they receive the highest standard of care in hospital. AQ is based on simple evidence–based interventions as agreed by clinicians that are driven in tandem by clinicians and managers to:

Save lives Improve the quality of life for patients Facilitate CCG assurance frameworks Incentivise improvement in quality to international levels Achieve value for money Creates a system that collaborates

The CQUIN will measure the proportion of patients that received all of the relevant interventions and are therefore a measure of ‘perfect care’. The goal for this measure is to reflect high quality of care but not necessarily 100% attainment


for each measure. The underlying clinical process measures for Hip & Knee Replacement in 14/15 are:

Prophylactic antibiotic received within one hour prior to surgical incision. Prophylactic antibiotic selection for surgical patients (policy to be provided

at external audit). Prophylactic antibiotics discontinued within 24 hours after surgery end

time. Recommended Venous Thromboembolism prophylaxis ordered. Appropriate Venous Thromboembolism prophylaxis administered within 12

hours of surgery end time. Appropriate VTE duration post-surgery (information only).

Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys. PROMs have been collected by all providers of NHS-funded care since April 2009, and provide an indication of the outcomes or quality of care delivered to NHS patients. We will continue to monitor patient response rates as part of a local CQUIN indicator with a graduated quarterly target to achieve greater than 80% compliance by quarter four of 2014/15.

Maintaining Endoscopy Standards is a priority for Euxton Hall for 2014/15 and our JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation inspection is due later in 2014. Biannual submission to GRS (Global Rating Score) continues, enabling us to assess how well we provide a patient-centred service.

Patient Experience: The Friends and Family Test aims to improve the experience of patients in line with the NHS Outcomes Framework. The friends and family survey now includes an audit of staff opinion as well as in-patient and day-case patients, and will also be rolled out to include the out-patient experience.

The Friends and Family Test will provide timely feedback from patients about their experience and results from this survey will be reviewed and shared with the hospital departments. The hospital has been set the national expectation of a 30% response rate across all hospital areas.

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 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 nursing teams. We will continue to monitor posts on NHS choices and remain committed to improving patient satisfaction.

Equality Delivery System – Euxton Hall 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 StatementsThe 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 Euxton Hall Hospital provided NHS services across eight surgical specialties.

Euxton Hall Hospital has reviewed all the data available to them on the quality of care in all of these NHS services.

The income generated by the NHS services reviewed in 1st April 2013 to 31st March 2014 represents 74.6% per cent of the total income generated from the provision of NHS services by Euxton Hall 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 hospitals senior managers together with Regional and Corporate Senior Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement.


In the period for 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 1 April 2013 to 31st March 2014 Euxton Hall Hospital participated in two national clinical audits..

The national clinical audits that Euxton Hall 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) 93.4

Elective surgery (National PROMs Programme) 61.1

The reports of these national clinical audits were reviewed by the hospital’s Clinical Governance Committee.

Local Audits

The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were reviewed by the Clinical Governance Committee and Euxton Hall Hospital. The clinical audit schedule can be found in Appendix 2

2.2.3 Participation in Research

There were no patients recruited during 2013/14 to participate in research approved by a research ethics committee.

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

A proportion of Euxton Hall Hospital’s income in 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)

Euxton Hall Hospital is required to register with the Care Quality Commission and its current registration status on 31st March 2014 is registered without conditions/registered with conditions.

Euxton Hall 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 the importance of accurate data input and have sufficient technical competence

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

NHS Number and General Medical Practice Code Validity

Euxton Hall Hospital’s 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 out patient 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 score overallscore for 2013/14 was 83% and was graded ‘green’ (satisfactory).

Clinical coding error rate

Euxton Hall 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 Euxton Hall’s 2013/14 Quality Account

Healthwatch :

A copy of the Quality Accounts has been sent to Healthwatch

Chorley and South Ribble Clinical Commissioning Group

Ramsay Health Care Quality Accounts 2013/14

NHS Chorley and South Ribble CCG have welcomed the opportunity to comment on the Ramsay Health Care annual quality accounts for 2013/14.

The progress that we have undertaken has been to forward the accounts to the Joint Quality Improvement Committee (JQIC), which is a sub-committee of the CCG Governing Body, for review and comments. Ramsay Health Care was also invited the JQIC to present their accounts at the July Committee Meeting.

Throughout the year the CCG, in partnership with Ramsay Health Care, has reviewed and discussed quality in terms of clinical excellence, effectiveness and patient safety on a quarterly basis. Through these discussions and the review of supporting evidence, it is our belief that the information contained within the quality accounts gives an overarching view of the quality of services provided over the last year.

It is evident from the quality accounts that Ramsay Health Care is constantly striving to improve clinical safety and standards by utilising a systematic process of governance which includes audit and feedback.


http://www.nhs.uk/NHSEngland/thenhs/about/Pages/getinvolved.aspx

The CCG is pleased to recognise that the clinical priorities identified for 2013/14 have all been achieved, including:

The first patient led assessments of the care environment (PLACE) assessment scored highly against the four areas of cleanliness, food, privacy and the condition of the facility.

100% compliance rate attributed to their local CQUIN targets for smoking cessation and alcohol awareness.

National CQUIN targets demonstrated highly favourable results. At both Fulwood Hall and Renacres, 99% of patients and 97% of staff indicated that they would be ‘extremely likely to recommend’ the hospital when undertaking the Friends and Family Test. These results were higher at Euxton Hall, who demonstrated scores of 100% and 98% respectively.

Continuously achieving the compliance target of 97% for VTE Risk Assessment.

Fulwood Hall Hospital achieved JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation in 2013, which demonstrates compliance against the four domains of clinical quality; quality of patient experience; workforce and training. This is noted to be a priority for both Euxton Hall and Renacres Hospitals for the coming year; the JQIC wished to note this as an excellent achievement.

The CCG would welcome the opportunity to view evidence of such good practice throughout the year.

Core quality account indicators remain consistently high against the national averages, with exception of PROMS (Patient Reported Outcome Measures) scores, which can largely be attributed to low volumes of applicable patients. The CCG recognises that action has been taken to improve the returns rate of PROM’s questionnaires and is pleased to see that this has been identified as a clinical priority in 2014/15. This has resulted in the formulation of a CQUIN target in relation to this quality measure.

Ramsay Health Care consistently maintains high levels of patient and staff satisfaction. The CCG is also pleased to recognise that individualised responses to patient comments are entered onto the NHS Choices website, further ensuring commitment to high standards of patient care.

The CCG would also welcome evidence in relation to any action taken to improve practice and patient care as a result of patient and staff feedback, thereby demonstrating an ongoing commitment to providing evidence based, quality, patient care.


Ramsay Health Care has identified theatre safety checks and physiotherapy documentation checks as priorities for clinical documentation audit. The CCG look forward to sharing any action plans as a result of these audits in order to provide further quality assurance in relation to service provision.

The CCG value the collaborative relationship established with colleagues at Ramsay Health Care and look forward to continuing this close working relationship in order to continually improve the safety, effectiveness and experience for patients over the coming year.

Yours sincerely

Jan Ledward

Chief Officer


Part 3

Review of quality performance 2013/2014

Statements of quality deliveryReview of quality performance 1st April 2013 - 31st March 2014

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 2014The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation.

The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way.


It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All management systems, clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others.

Several models have been devised to include all the elements of Clinical Governance to provide a framework for ensuring that it is embedded, implemented and can be monitored in an organisation. In developing this framework for Ramsay Health Care UK we have gone back to the original Scally and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of all the necessary strategies, policies, systems and processes for effective Clinical Governance. The domains of this model are:

• Infrastructure• Culture• Quality methods• Poor performance• Risk avoidance• Coherence

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


Period Euxton2012/13 NVC05 02013/14 NVC05 0

National Expected Deaths:

Period Best Worst AverageApr12 - Mar13 RBA 0.1 RWH 44.0 Eng 20.4

Jul12 - Jun13 RBA 0.0 RWH 44.1 Eng 20.2


Period Euxton2012/13 NVC05 0.02013/14 NVC05 0.0


PPROMs

Euxton Hall 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.

Hernia repair

National PROMs:

Period Best Worst AverageApr12 - Mar13 NT415 0.157 NVC27 0.015 Eng 0.085

Apr13 - Sep13 RTG 0.138 RNA 0.019 Eng 0.086

Euxton Hall Hospital PROMs:

Period EuxtonApr12 - Mar13 NVC05 0.084Apr13 - Sep13 NVC05 *

Varicose Veins

National PROMs:

Period Best Worst AverageApr12 - Mar13 RV8 5.14 NT350 -15.92 Eng -8.374

Apr13 - Sep13 RTD -9.74 RLN -10.52 Eng -9.46


Period EuxtonApr12 - Mar13 NVC05 *Apr13 - Sep13 NVC05 *


Hip Replacement

National PROMs:

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



Knee replacement

National PROMs:

Period Best Worst AverageApr12 - Mar13 NT219 20.37 RAP 12.46 Eng 16.01

Apr13 - Sep13 RDE 20.09 RM1 14.32 Eng 16.74



Readmissions

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

Euxton Hall Hospital Readmissions:

Period Euxton2012/13 NVC05 5.312013/14 NVC05 0

VTE assessment

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%

Euxton Hall Hospital:

Period Euxton13/14 Q3 NVC05 99.8%13/14 Q4 NVC05 99.8%

Euxton Hall Hospital considers that this data is as described; we monitor compliance monthly and agree an action plan if completion rates drop below 95% maintaining a target above the national average. Euxton Hall Hospital will continue to audit to maintain the quality of its services.

C Difficile rate

National C Difficile rate:

Period Best Worst Average


2012/13 Several 0 RNA 58.2 Eng 22.22013/14 Several 0 RVW 30.8 Eng 17.3



Euxton Hall Hospital considers that this data is as described as there have been no reported cases of C Difficile. Euxton Hall Hospital intends to maintain this rate by ensuring robust infection control measures are in place.

Patient safety

National 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



Euxton Hall Hospital considers that this data is as described, we have a low level of patient incidents reported. Euxton Hall Hospital ensures a safe environment is maintained with all staff undertaking training and competency assessments and a robust audit system. All incidents and accidents are reviewed at clinical governance, health and safety and medical advisory committee and action plans developed and lessons learned shared.

SUI’s Severity level 1

National SUI’s Severity level 1


Period Best Worst AverageJul - Sep 12 NA NA NA

Oct11 - Sep12 NA NA Eng 11,563


Period Euxton2012/13 NVC05 2.9%2013/14 NVC05 0.0%

Euxton Hall Hospital considers that this data is as described, there has been no level 1 severity incidents reported in the last 12 months.

* Volumes were too low to be reported.


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

Euxton Hall Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 3 years.

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

Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored. Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a Corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year. A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice.

Programmes and activities within our hospital include:

The dedicated infection 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. There have not been any trends identified in the period. As can be seen in the graph below our infection control rate has increased over the last year due to the improved monitoring and reporting process employed by our dedicated infection control nurse. However this has been reviewed by our consultant microbiologist and rates remain below the national average.

2011/12 2012/13 2013/140

0.2

0.4

0.6

0.8

1

1.2

1.4

Infection Rates


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 Euxton Hall Hospital, providing us with a patient’s eye view of the buildings, facilities and food we offer, giving us a clear picture of how the people who use our hospital see it and how it can be improved.

The main purpose of a PLACE assessment is to get the patient view.

2013 PLACE results: Cleanliness - 92.54%Condition, Appearance and Maintenance - 84.25%Food - 95.43%Privacy, Dignity and Wellbeing - 90.32%


An action plan was compiled in conjunction with a refurbishment plan to rectify some of the low scores for general maintenance. Similarly a review of clinical equipment i.e. trolleys was carried out and purchased where required.

As a day case facility patients did not have access to the internet this reflected a low score for privacy and dignity and has since been rectified. An active maintenance programme was introduced to ensure the condition and maintenance of the facilities is maintained to 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 we keep up to date with all safety issues.

3.3 Clinical effectiveness

Euxton Hall 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 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

0.050.1

0.150.2

0.250.3

0.350.4

0.450.5

Return to Theatre Score


Retrnn

to The

atre

(Percentage of Adm

issiosns)

Euxton Hall Hospital continues to have a very low return to theatre rate as a percentage of overall admissions.

3.3 Patient experience

All feedback from patients regarding their experiences with Ramsay Health Care are welcomed and inform service development in various ways dependent on the type of experience (both positive and negative) and action required to address them.

All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour – letters and cards are displayed for staff to see in staff rooms and notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly.


All negative feedback or suggestions for improvement are also feedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.

Patient experiences are feedback via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy.

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

Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48hrs of a patient making a comment on their web

survey Yearly CQC patient surveys Friends and family questions asked on patient discharge ‘We value your opinion’ leaflet 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 care

3.3.1 Patient Satisfaction Surveys

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

Every patient 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 48 hours of receiving them so that a response can be made to the patient as soon as possible.


2012/13 2013/140

20

40

60

80

100

120

99.6 95.0

Satisfaction ScoresNHS/Private Patients


Satisfaction

Scores

Please note a change of satisfaction survey in early 2013 means the data year on year is not comparable.

3.4 Euxton Hall Hospital Case Study

During the latter part of 2013 a working group was established to look into how Euxton Hall Hospitals private service could be improved. As an outcome from this group it was decided that to evolve and improve the service a Private Patient Account Manager would be piloted.

The role would be responsible for coordinating all aspects of the private patients pathway from initial enquiry through to post discharge and would be at hand should the patient require any assistance during this time.

The role was piloted for four months and the feedback was extremely positive for the service that was received.

This is a role that will be developed in 2014 to fit into the existing roles within the hospital.


3.5 Patient Feedback (Received via Friends & Family January 2014)

“Attitude of all carers was friendly and professional. I felt very safe in their hands. Thank you.”“The hospital is very clean and presentable. The staff are very friendly making the place a very relaxed environment.”

“Doctors and nurses very helpful and pleasant. Everything explained really well. Rooms were clean and comfortable and very private. All in all a very extremely satisfactory experience.”

“Speed, courtesy and privacy - all excellent. Lovely helpful nursing staff.”

“Excellent facilities, excellent privacy, wonderful nurses, procedure performed very quickly, my comfort considered during procedure.”

“Fast, efficient and very caring. I was looked after very well.”

“Very helpful and caring. Would recommend to friends and family.”

“The whole experience was fabulous. I was a very nervous patient but the surgeon, anaesthetist and nurses were all fabulous. Thank you. Very happy!”

“Good service and information.”

Excellent staff with excellent bedside manner. Couldn't do enough to make me feel comfortable.


Appendix 1

Services covered by this quality account

Services Provided Peoples Needs Met for:

Treatment of Disease, Disorder

Or injury

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

All adults 18 yrs and over

Surgical

Procedures

Breast surgery, Cosmetics, Day and Inpatient Surgery, Ear, Nose and Throat (ENT), Gastro-enterology, General surgery, Gynaecological, Orthopaedic, Pain Control, Podiatry, Urology, Spinal, Vascular

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. Each arrow links to the audit to be completed in each month.


Euxton Hall HospitalRamsay 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:

David WintersGeneral Manager


Euxton, Chorley

Lancashire, PR7 6DY

01257 276 261

www.euxtonhallhospital.co.uk


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