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Nottingham Woodthorpe 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

.2.7 Stakeholders views on 2010/11 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account indicators

3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

3.5 Case Study

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

Welcome to Ramsay Health Care UK Nottingham Woodthorpe Hospital is part of the Ramsay Health Care GroupThe 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 46

Introduction to our Quality Account

This Quality Account is Nottingham Woodthorpe Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and 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 1

1.1 Statement on quality from the General Manager

Simon Milner, General Manager


As General Manager of Nottingham Woodthorpe Hospital, I believe that this hospital is clinically driven and our goal is to support our clinicians in delivering the highest quality care to our patients.

Not only that, but we aim to produce evidence to this effect whether it be qualitative or objective – we will be able to demonstrate our capabilities, and clinical excellence.

Our Hospital Vision is that:-

“As a committed team of professional individuals we aim to consistently deliver quality holistic Acute Inpatient and Day Case Services with exemplary customer care. This we believe we are able to achieve by continually updating our staffs’ skills and competencies. We strive to further develop our knowledge in order to deliver evidenced based clinical practice”.

This Quality Accounts document details our performance over the past year indicating how we have improved on the high standards of clinical care the actions that we have taken over the past year.

Quality extends not only to the service we deliver to our patients but to our other customers – Consultants, GPs, Commissioners, other Trusts and by no means


last, the people who work for us. To understand how we deliver our services, and the quality standards we reach is critical in our understanding of where we can improve and how.

Where appropriate, Nottingham Woodthorpe Hospital participates in local, corporate and national systems of quality review that are sometimes mandatory, sometimes voluntary, but all times we are honest in our responses. It is to our benefit that we benchmark honestly against our peers, and that we take the opportunity to learn from those facilities and people delivering better outcomes, in order to drive up our own standards Quality Accounts 2014/15

To ensure that we deliver clinical excellence depends on everyone in our hospital and we have a training and education plan which involves all members of our administrative, operational and clinical teams. The emphasis on training and education is high and strongly encouraged in order that we develop our people, as well as deliver standards that we can be proud of.

Every individual member of staff is crucial to the success of our Hospital and they value the contribution that they make in delivering great customer care.

In addition to our people contributing to the quality of services delivered, we work closely with our consultant colleagues who, for the first time this year through their MAC representatives, have responded positively to sharing the outcomes of their clinical work in many areas. This is to be commended, but at the same time, will be something Nottingham Woodthorpe Hospital can be proud to show, as we pride ourselves in having consultants with the highest standards in the area

To ensure a coordinated approach to the delivery of care for patients and to monitor the adherence to professional standards and legislative requirements the Clinical Governance Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and safety performance of the hospital. These committees have reviewed and commented on the details within these Quality Accounts.

If you would like to comment or provide me with feedback then please email at [email protected] or contact on 0115 920 9209


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.

Simon MilnerGeneral ManagerNottingham Woodthorpe HospitalRamsay Health Care UK

This report has been reviewed and approved by:

Ramsay Health Care UK Regional Director: James Beech

CCG Lead: Linda Clarke

Medical Advisory Committee (MAC) Chair: Mr Anwar Zaman (sent and response awaited)

Clinical Governance Committee Chair: Dr Ndu Okonkwo (sent and response awaited)


Welcome to Nottingham Woodthorpe HospitalNottingham Woodthorpe Hospital has provided healthcare to the people of Nottingham since 1877 and is conveniently located towards the north of Nottingham city centre.

Today, we are a modern well equipped hospital with 41 private bedrooms (including a Level 2 High Dependency Unit), two theatres (with laminar air flow), and a Minor Procedures Theatre with Endoscopy Suite and 10 Consulting Rooms.

The hospital provides NHS and private inpatient and outpatient facilities for:- Orthopaedic surgery General surgery including gastrointestinal Gynaecology Bariatric surgery Colorectal surgery Cosmetic and Plastic surgery Dermatology Upper and lower diagnostic Endoscopy procedures Ophthalmic surgery Oral and Maxillofacial surgery Spinal surgery Vascular surgery Urological surgery General medicine Physiotherapy, including shockwave therapy, Sports Medicine and

acupuncture Diagnostic imaging services including MRI and CT

We provide safe, convenient, effective and high quality treatment for adult patients (excluding patients below the age of 18 years), whether privately insured, self-pay, or from the NHS.

A high percentage of our patients have come from the NHS sector with patients choosing to use our facility through “Choose and Book‟. Our services help to ease the pressure on local NHS facilities and our Hospital Management Team work closely with local CCGs and the local NHS Trust to ensure improved access for patients and relief on bed pressures, as required. In addition, Nottingham


Woodthorpe Hospital has undertaken some work with the CCGs outside the Standard Contract.

We have close links with GP surgeries, providing information, training and liaison in order to monitor their needs and the requirement of the local population.

For the Year-to-date (July 2013 to end-May 2014) Nottingham Woodthorpe Hospital has seen 4,413 admissions:

Insured: 7.5% (331 patients) Self-Pay: 6.0% (265 patients) NHS: 86.5% (3,817 patients)

Nottingham Woodthorpe Hospital employs the following staff

Senior Management Team General Manager Matron Operations Manager Finance Manager Sales & Marketing Manager

Clinical DepartmentsManagers

Surgical Ward Manager Medical Ward Manager Theatre Manager Outpatient Manager Physiotherapy Radiology Pharmacy Decontamination Lead

19 Registered Nurses working within the Ward, Outpatients and Theatres 8 Senior Staff Nurses working within the Ward and Theatres 1 Senior Operating Theatre Practitioner 4 Operating Department Practitioners 18 Health Care Assistants working within all clinical departments 2 Radiographers1 Sonographer1 Senior Physiotherapist2 Physiotherapists1 Pharmacy technician


3 Sterile Services Technicians29 Administration Staff working within Reception, Bookings, Business

Non-Clinical Departments1 PA to GM1 Reception/Admin Team Leader13 administration staff in Business Office, Hospital Administration, Medical Secretaries and Medical Records 1 GP Liaison Manager1 Hospital Services Advisor1 Supplies Manager 1 Maintenance Manager, 1 Assistant Maintenance Assistant 2 Theatre Porters 1 Housekeeping Team Lead5 Housekeeping staff 2 Chefs supported by 6 Catering staff

GP CommunicationNottingham Woodthorpe Hospital employs a GP Liaison Officer who maintains and establishes relationships with GPs and the practice staff from Nottingham and the surrounding areas. A GP visit schedule is maintained whereby surgeries are contacted and visited on a regular basis. GPs are sent regular newsletters and updates, and information packs containing details about the hospital and how to refer are distributed.

Nottingham Woodthorpe Hospital delivers a programme of educational visits during practice learning times whereby a consultant and the GP Liaison Officer will visit GP surgeries with a topic of interest for a “Lunch & Learn” session. GP Educational evenings are also held at the hospital.

Outside activities which show an involvement in the community include hosting public open evenings for various clinical specialities.


Part 2

2.1 Quality priorities for 2014/2015Plan for 2014/15

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

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

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

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

Priorities for improvement

2.1.1 A review of clinical priorities 2013/14

Patient Safety WHO Surgical safety checklist This has been implemented effectively to ensure that the highest possible safety standards pre-operatively are ensured before and during all operations undertaken in the facility.


Venous-Thromboembolism assessment In September 2008, the Department of Health issued its guidance on Risk Assessment for Venous Thromboembolism (DH 2008). The objective is to improve the quality of patient care by minimising the risk of VTE incidents. Nottingham Woodthorpe Hospital submits data to evidence compliance with the National VTE Commissioning for Quality and Innovation Goal that all patients should have a VTE risk assessment. Nottingham Woodthorpe Hospital’s priority for 2013/14 was to maintain and improve the current compliance rate.

Cleanliness and infection prevention The hospital continues to screen all patients for MRSA prior to admission and all staff has a mandatory requirement to undertake hand hygiene training. We maintain our regular audit programme which includes hand hygiene, urinary catheter and intravenous line care, and our cleaning standards and physical environment. We also participate in the Health Protection Agency data collection for surgical site infections following hip and knee joint replacements.

Never events Preventing the occurrence of Never Events will remain a clinical priority for 2014/15.

JAG accreditation JAG Accreditation was not achieved in 2013/14. However, Nottingham Woodthorpe Hospital is in a good position to achieve this in 2014.

National Joint Register Nottingham Woodthorpe Hospital has maintained its consistently good scores for data submission to the National Joint Register. The National Joint Register records the details of patients undergoing major joint replacement surgery and the type of prosthesis (new joint) they are given. Patients’ details are only added to this register with their written consent. We continue to submit data to the NJR.

Clinical and other training Nottingham Woodthorpe Hospital will continue to ensure that patients are cared for by well trained, competent staff. Providing quality care for patients is a high priority for us and all relevant clinical staff will be supported through training and protected time to achieve competency level education.

This year the staff have undertaken competency based training in infection prevention and control which includes hand hygiene. Intermediate Life Support (ILS) and/or Advance Life Support (ALS) training is mandatory for all clinical staff at all levels working in acute areas and this year we also provided AIM (Acute Illness Management) training. All staff at Nottingham Woodthorpe Hospital who are involved in any aspect of a blood transfusion or who handle blood products have been formally assessed as competent in order to be allowed to participate in this aspect of care.

Safeguarding The hospital takes its responsibility for safeguarding vulnerable members of society seriously. We will continue to ensure that all staff working within the hospital has the


appropriate level of DBS, immunisation, reference and other mandatory checks appropriate to their role, prior to commencing any position offered. We will continue to provide training, reviewing the content in light of local multi-agency and Ramsay UK policies procedures, and ensure that staff has the necessary resources available to enable them to manage any concerns appropriately and in a timely manner.

Staffing To ensure that adequate numbers of skilled staff are available to care for our patients’ staff rotas are prepared in advance. When determining how many staff and what skills are required, the dependency of patients and the amount of time each requires is taken in to account. We have Bank staff to provide additional cover as required.

Nottingham Woodthorpe Hospital has implemented a Ramsay-wide electronic rostering system called Allocate. The system sets-up rotas in line with patient numbers and specific local skill mix requirements. The benefits of the system are already being felt as patient safety is maintained, efficiencies gained and staff engagement increased

Clinical effectiveness Ambulatory Day Care – better outcomes and improving patient experience Ambulatory Care is the admission of selected patients (both medical and surgical) to hospital for a planned procedure, returning home the same day i.e. the patient does not incur an overnight stay. Current Day Case volumes, as a percentage of total cases sit at 58% and increase of 7 percentage points over the same period in 2012/13. This reflects the changing nature of healthcare, the demands of patients and the facility’s ability to respond accordingly.

Pre-operative Assessment Nottingham Woodthorpe Hospital’s Pre Assessment team continues to deliver high-quality services, minimising the risk to patients and optimising their ability to undertake the surgery with the best outcomes possible.

Improve National Benchmarking It was recognised that Nottingham Woodthorpe Hospital needed more transparency other independent sector providers and the NHS in order to monitor and improve our services.

PROMS Audit Nottingham Woodthorpe Hospital currently participates in the outcome data known as PROMS for the following surgical procedures:-

Hernia repair; Total knee replacement and Total hip replacement procedures

All patients who undergo these procedures receive a pre and post-operative questionnaire which they complete and the results are collated by The Royal College of Surgeons. This incorporates results relating to the Oxford Hip and Knee scores.


The results, which are very encouraging for the hospital, are shared with the medical and clinical staff through the Medical Advisory Committee, Clinical Governance Committee, and Clinical Effectiveness meetings. Reviewing this data also provides the opportunity to identify poor outcomes and examine poor practice if and when it exists.

Benchmarking is undertaken through the national PROMS website. Link: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295

Patient experience Patient satisfaction survey Nottingham Woodthorpe Hospital has always achieved a high level of patient satisfaction.

A Ramsay-wide “We Value your Opinion” survey is used for all patients to assess views on a number of areas including clinical and non-clinical factors as well as how care was delivered

Friends and Family Survey A NHS-wide ‘Friends and Family’ test to improve patient care and identify the best performing hospitals in England was announced in 2012 by the Prime Minister.

From April 2013 patients at Nottingham Woodthorpe Hospital have been invited to take part in this anonymous survey. By completing a simple questionnaire asking whether they would recommend our hospital to their family and friends. Scores will be published on the NHS Choices Website www.gov.uk.

Nottingham Woodthorpe Hospital asks all patients to complete the Friends and Family test survey to enable us to collate patient opinion and act immediately upon any concerns both for NHS patients and private patient

Additional Patient-focussed improvements in 2013/14Introduction of the National Patient Safety ThermometerThe National Patient Safety Thermometer is a national initiative which has allowed us to monitor the level of harm our patients may be exposed to. The monitoring takes place on a pre-determined date each month and is applicable to all in-patients on that set date. Data is completed on a template and submitted directly to the Department of Health Information Centre and monitors the incidence of falls, VTE assessment and preventative treatment, and urinary infections. Through submitting this data on a monthly basis, we have been able to benchmark ourselves against other Hospitals within Ramsay Health Care and within the NHS.


http://www.gov.uk/

Implementation of RiskManIn 2012/13 a new incident reporting system was implemented called RiskMan across the company which has allowed greater accuracy in recording incidents and also supports enhanced data and trend analysis. There is now an improved ability to identify areas concern relating to patient safety and calculate any trends.

Using this system, Nottingham Woodthorpe Hospital has seen the total number of incidents reported rise but with the significant majority of incidents are classified as not causing harm to anyone. This is an indicator of a safety conscious organisation; one which is willing to report and analyse all incidents, whether they cause harm or not to ensure we learn and improve further.

This information is shared with the local CCG Quality team to provide assurance of the safety of our services and allows us to be benchmarked against other providers. We will continue to share this type of information with our CCG during 2014/15

2.1.2 Clinical Priorities for 2014/15

Clinical EffectivenessNottingham Woodthorpe Hospital has a Clinical Governance Team and Committee that meet monthly throughout the year to monitor quality and effectiveness of care. Clinical effectiveness was chosen in order to evidence that Nottingham Woodthorpe Hospital is striving to strengthen governance by encompassing the following key areas:

1. Dementia Care2. Improved incident reporting3. NHS Safety Thermometer Audit4. PROMS ( Patient Reported Outcome Measure Studies)

Dementia CareNottingham Woodthorpe Hospital is committed to improving dementia care by improving the way we identify people with dementia, assess and investigate symptoms and appropriately refer for support.

When a person finds that their mental abilities are declining, they and their families often feel vulnerable and in need of reassurance and support. By training our staff appropriately we will provide them with the understanding of the disease and skills to identify dementia, offer appropriate support whilst in our care and appropriately refer for specialised support.

To deliver against the Commissioning for Quality & Innovation (CQUIN) 2014/15 indicator we will extend the assessment of patients attending pre assessment appointments. All patients over the age of 75 years will be asked if they have


experienced any memory gaps. Patients who meet the criteria will then be asked to take part in a short cognitive test. This will allow us to alert the patient’s GP so that appropriate diagnosis and treatment can be provided. We will monitor the levels of referrals back to the patients’ GPs to ensure all patients receive appropriate onward referral where required. We will report our performance to our Commissioners (OCCG) through monthly reports and discussion at contract meetings.

Training will take into account the rising number of patients expected to have dementias, especially in our medical ward, and specific training shall be given accordingly, eg training from The Alzheimer’s Society, Protection of Vulnerable Adults (POVA), and communication with CityCare in assessing and delivering appropriate care

Incident reportingClinical 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.

RiskMan (an incident reporting system) has been introduced to record and report on incidents and provide useful information relating to trends for action to ensue.

Incident and near-miss reporting is encouraged to ensure effective learning in a no blame culture. Nottingham Woodthorpe hospital receives clinical feedback by department managers following incidents ensuring staff fully understand lessons learnt and plan actions accordingly in order to address issues identified. The outcomes will then be reported onto the RiskMan site which is an instant reporting data base.

A Quality Improvement Manager will be appointed to manage all elements of clinical risk and improve the outcomes. This will involve training of staff, competency and monitoring of actions to deliver a holistic approach to quality and responsiveness to incidents.

NHS Safety ThermometerIt was recognised that we needed more transparency between ourselves and other independent sector providers/the NHS in order to monitor and improve our services. Nottingham Woodthorpe hospital carry out a VTE risk and falls assessment on all admitted surgical patients as per Ramsay Policy No CM001 and adheres to National Institute for Clinical Excellence (NICE) Guidance 2010. Compliance is audited through a robust corporate and local audit programme and results/action plans reviewed through Clinical Governance. Compliance results are benchmarked through the National Statistics at: http://transparency.dh.gov.uk/category/statistics/vte/


http://transparency.dh.gov.uk/category/statistics/vte/

Patient Reported Outcome Measures (PROMS)Increasing the use of Patient Reported Outcomes Studies (PROMS), Nottingham Woodthorpe Hospital routinely issues the National PROMS questionnaires to patients undergoing hip, knee, hernia, varicose vein and cataract surgery (PROMs for Hips, Knees and Hernia Repairs are reported by Nottingham Woodthorpe Hospital). These are used to gain a better understanding of treatment outcomes from a patient point of view. To improve the post-operative survey response and in turn allow more accurate health gain measurement, we will be improving our communication to patients to stress the importance of completion prior to discharge from our care

Consultants can access the survey information within their own Trusts for all patients, including those treated at Nottingham Woodthorpe Hospital. We continue to monitor compliance return rate in order to ensure that we continue to learn from patient feedback, we will be concentrating our efforts on this initiative throughout 2014


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 2013/1, Nottingham Woodthorpe Hospital provided the following NHS services:

Orthopaedic surgery General surgery including gastrointestinal Gynaecology Bariatric surgery Colorectal surgery Dermatology Upper and lower diagnostic Endoscopy procedures Ophthalmic surgery Oral and Maxillofacial surgery Spinal surgery Vascular surgery Urological surgery General Medicine (Trust-referred cases only) Physiotherapy, including shockwave therapy, Sports Medicine and

acupuncture Diagnostic imaging services including X-Ray, Ultrasound, MRI and CT

Nottingham Woodthorpe 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 1 April 2013 to 31st

March 2014 represents 82.5% of the total income generated from the provision of NHS services by the Nottingham Woodthorpe Hospital for 1 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.

Except where otherwise stated, for the period for 2013/14 the indicators on the scorecard which affect patient safety and quality are as follows. All other data (*) is for the period 1/7/13 – 31/5/14:

Human Resources Staff Cost % Net Revenue: 29%*

HCA Hours as % of Total Nursing: 37.5% HCA to 62.5% RGN

Agency Cost as % of Total Staff Cost 2.18% Total3.27% Direct

Ward Hours PPD: 5.29

% Staff Turnover 16.4% Total8.6% Clinical28.2% Support

% Sickness 4.79%

% Lost Time 17.9%*

Appraisal % 84%

Mandatory Training % 47.1%*

Staff Satisfaction Score 3.87 (Ramsay average: 4.54)

Number of Significant Staff Injuries 1 (RIDDOR reported)

PatientFormal Complaints per 1000 HPD's 3.6 (0.36%)

Patient Satisfaction Score 96.8% (Friends and Family)

91% (Qa Research)

Readmissions per 1000 Admissions 4 (0.047%)


QualityAudits undertaken to date show the following outcomes:

Hand hygiene 97% Urinary catheter care bundle 86% Surgical site infection 88% Blood transfusion 92% Prescribing 93% Surgical safety checklist 87% MRSA positive 0% Cleaning standards 100% Medicine management 90% Controlled drugs 94% Anaesthetic standards 90%

2.2.2 Participation in clinical audit

During 1 April 2013 to 31st March 2014 Nottingham Woodthorpe Hospital participated in four national clinical audits and zero national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquiries that Nottingham Woodthorpe Hospital participated in, and for which data collection was completed during 1 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

Participation

Yes, No, N/A

% cases submitted

National Joint Registry (NJR)Yes 88.22% hips

88.49% knees

Elective surgery (National PROMs Programme)

Yes 28.90% hip 26.80% knee 15.90% hernia

Cardiac Arrest (NationalCardiac Arrest Audit)

Yes N/A

NHS Safety Thermometer Yes 100%

The reports of four national clinical audits from 1 April 2013 to 31 st March 11 2014 were reviewed by the Clinical Governance Committee and Nottingham


Woodthorpe Hospital intends to take the following actions to improve the quality of healthcare provided.

National Joint Registry (NJR)We have improved the NJR data collection and input by identifying those patients eligible for NJR on the basis of their episode data on our patient administration system.

This has resulted in a significant improvement and our current performance for data input in 2014 is 88%.

Local AuditsThe reports of 70 local clinical audits from 1 April 2013 to 31 st March 2014 were reviewed by the Clinical Governance Committee and Nottingham Woodthorpe Hospital intends to take the following actions to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2.

Environmental Audit demonstrated that several chairs had torn and frayed fabric on the arms of chairs presenting an infection control risk.

Action: Planned refurbishment of soft furnishings in patient areas was reviewed by SMT (Senior Management team meeting and this has resulted in new furniture being purchased

Blood transfusion audit showed that some patients were not receiving an information leaflet post transfusion.

Action: Nursing staff required to document that they talked to the patient about the post-operative transfusion, alternatives of the transfusion, and that leaflets were given to patients.

Nutrition and hydration audit identified lack of compliance. Action: A new fluid balance (EWS) chart has been implemented with

training for all staff to be provided. Re-audit for compliance to be performed.

2.2.3 Participation in Research

There were no patients recruited during 2010/11 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 Nottingham Woodthorpe Hospital income in from 1 April 2013 to 31st March 2014 was conditional on achieving quality improvement and innovation goals and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework.

2.2.5 Statements from the Care Quality Commission (CQC)

Nottingham Woodthorpe Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions

The Care Quality Commission (CQC) attended Nottingham Woodthorpe Hospital to undertake an unannounced inspection, reporting on 8 th March 2014. Staff, patients and some clinical departments were visited, along with a thorough investigation into our credentialing and training databases. The CQC was impressed with the standard of care, and processes in place. Nottingham Woodthorpe Hospital was found to have met all standards required in the areas inspected. The detailed report can be found on the CQC website at http://www.cqc.org.uk/location/1-127032975.

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


http://www.cqc.org.uk/location/1-127032975

2.2.6 Data Quality

Statement on relevance of Data Quality and your actions to improve your Data Quality

Nottingham Woodthorpe Hospital will be taking the following actions to improve data Weekly Data Quality reports are issued to highlight any errors or omissions in the data. These are reviewed and actioned as required.

We complete regular audits of our medical records. We have identified opportunities for improvement and have tasked our Consultants to improve their documentation. Regular re-audit is being completed. Integrated Medical Records are to be introduced following a thorough review of processes and clinical risk.

Monthly exception reports are monitored to ensure that there are no omissions in the data we are submitting to our commissioners through Secondary Uses Service (SUS).

Robust clinical audit calendar (Appendix 2). All of these audit results are discussed at the MAC, Clinical Governance, and Health and Safety meetings, and results are compared against previous year results

NHS Number and General Medical Practice Code Validity

Nottingham Woodthorpe Hospital submitted records during 2013/14 to the Secondary Uses 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 score overallscore for 2013/14 was 83% and was graded ‘green’ (satisfactory).

Clinical coding error rate

Nottingham Woodthorpe 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 2013/14 Quality Account

Statement from

Linda Clarke, Contract Support Officer, Collaborative Contracting,Greater East Midlands Commissioning Support Unit (GEM CSU) acting as Contract Support to the Nottingham Woodthorpe Hospital NHS Standard Contract, on behalf of East Midlands Clinical Commissioning Groups (CCGs)

GEM CSU, Collaborative Contracting lead on behalf of Nottingham City CCG and other East Midlands CCGs on the contract management for NHS referrals made to Nottingham Woodthorpe Hospital.

As stated in the report Nottingham Woodthorpe Hospital continues to receive a high number of referrals from the NHS mainly from GPs within Nottingham City and the surrounding areas, this referral pattern provides a statement of confidence from clinicians and patients about the services available at the hospital.

The majority of referrals made are for Trauma and Orthopaedic services, predominantly Hip and Knee procedures, and referrals are continuing to rise in other surgical areas including Gynaecology, Urology and ENT.

The Stakeholders congratulate the hospital on their continued achievement in relation to management of VTE Assessments, Cleanliness and Infection prevention, Mortality rates and responsiveness to patient needs.

It is notable in the 2013’14 report that Nottingham Woodthorpe Hospital includes details on their Core Quality Priorities: Mortality, Patient Reported Outcome Measures (PROMS), Readmissions, Responsive to Personal Needs, Venous


Thromboembolism, Clostridium Difficile Infection, Incident rates, Patient safety and the Friends and Families Test.

These quality priorities set out around Patient Safety and Patient Experience are paramount to ensure that the services provided by the hospital continue to meet the national Quality Standards set out in the NHS Standard Contract.

The GEM CSU contract support team will continue to work closely with Nottingham Woodthorpe Hospital to ensure that the priorities set out for 2014’15 and onwards continue to improve and that service improvement developments are encouraged that will help to sustain the achievements seen during 2013’14.


Part 3: Review of quality performance 2013/2014

Statements of quality delivery

Matron, Caroline HuntReview 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 2014

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

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


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

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

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

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

Mortality

Prescribed Information Related NHS Outcomes Framework Domain

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to— (a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator.

1: Preventing People from dying prematurely 2: Enhancing quality of life for people with long-term conditions

Expected Period Perioddeaths: Apr12 - Mar13 RBA 0.1 RWH 44.0 Eng 20.4 2012/13 NVC40 0.0

Jul12 - Jun13 RBA 0.0 RWH 44.1 Eng 20.2 2013/14 NVC40 0.0

Best Worst Average Norttingham


Nottingham Woodthorpe hospital considers that this data is as described for the following reasons.

In addition to providing surgical care and treatment, The Nottingham Woodthorpe hospital provides care and treatment for medical patients under the care of Physicians. The table above explains the number of expected deaths in the last year.

Nottingham Woodthorpe hospital continues to implement the following actions to improve and monitor this rate by:-

Completion of Corporate audits, incident investigation and root cause analysis of care episodes

Robust mandatory training programme compliance

Information sharing at Clinical Governance level locally, corporately and with our commissioners. Governance is also shared at local Medical advisory committee and risk management meetings.

PROMS (Patient Reported Outcome Measures)

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s patient reported outcome measures scores for— (i) groin hernia surgery, (ii) hip replacement surgery, and (iii) knee replacement surgery, during the reporting period.

3: Helping people to recover from episodes of ill health or following injury

PROMS: Period PeriodHernia Apr12 - Mar13 NT415 0.157 NVC27 0.015 Eng 0.085 Apr12 - Mar13 NVC40 *

Apr13 - Sep13 RTG 0.138 RNA 0.019 Eng 0.086 Apr13 - Sep13 NVC40 *


PROMS: Period PeriodHips Apr12 - Mar13 NT209 24.68 RKE 17.21 Eng 21.32 Apr12 - Mar13 NVC40 22.042

Apr13 - Sep13 NT318 25.44 RHQ 18.34 Eng 21.61 Apr13 - Sep13 NVC40 *

PROMS: Period PeriodKnees Apr12 - Mar13 NT219 20.37 RAP 12.46 Eng 16.01 Apr12 - Mar13 NVC40 16.117

Apr13 - Sep13 RDE 20.09 RM1 14.32 Eng 16.74 Apr13 - Sep13 NVC40 *




Nottingham Woodthorpe hospital considers that this data is as described for the following reasons

Nottingham Woodthorpe Hospital has achieved an above average result in all categories.

Nottingham Woodthorpe Hospital participates in the Department of Health PROM’s survey for hip, knee and hernia surgery for NHS & private patients. The PROMS hip questionnaire is a “before and after” assessment of the health gain that patients show following surgery. Unfortunately there are not enough ‘paired’ surveys on the HSCIC database to provide an adjusted health gain score for this period

Nottingham Woodthorpe hospital has taken the following actions to improve this score so the quality of its services can be consistently monitored

We continue to monitor compliance return rate in order to ensure that we continue to learn from patient feedback, we will be concentrating our efforts on this initiative throughout 2014.

Completion of Corporate audits, incident investigation and root cause analysis


Information sharing at ward level, raising staff awareness of the importance of compliance

Information sharing at Clinical Governance level locally, corporately and with our commissioners and through local Medical advisory committee meetings

Strict adherence to infection control policies


Readmissions

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged— (i) 0 to 14; and (ii) 15 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.

3: Helping people to recover from episodes of ill health or following injury

Readmissions: Period Period2010/11 RF4 0.0 RYR 15.8 Eng 11.04 2012/13 NVC40 3.862011/12 RF4 0.0 RYR 15.8 Eng 11.08 2013/14 NVC40 6.65


Nottingham Woodthorpe hospital considers that this data is as described for the following reasons

Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness & outcomes be addressed. As evidenced in the template above Nottingham Woodthorpe Hospital demonstrates readmission rates are below the average national rate compared to other sites and this, in part, is due to sound clinical practice & governance ensuring patients are not discharged home too early after treatment, are independently mobile and that patients are fully informed of individual discharge information.

Nottingham Woodthorpe hospital has taken the following actions to improve this score so the quality of its services can be consistently monitored:

Completion of Corporate audits, incident investigation and root cause analysis


Information sharing at Clinical Governance level locally, corporately and with our commissioners and also through our local Medical Advisory Committee meetings

Strict adherence to infection control policies


Contract meetings highlight any readmissions to Trusts that are flagged for review

Responsiveness to personal needs

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s responsiveness to the personal needs of its patients during the reporting period.

4: Ensuring that people have a positive experience of care

Responsiveness Period Periodto personal 2011/12 RYR 73.3 RF4 67.4 Eng 75.6 2012/13 NVC40 89.4

needs 2012/13 RYR 75.9 RJ6 68.0 Eng 76.5 2013/14 NVC40 90.8


Nottingham Woodthorpe Hospital considers that this data is as described for the following reasons;

Feedback from patients regarding their experience at The Nottingham Woodthorpe hospital is encouraged and is essential to inform our staff how care can be enhanced or adjusted to meet individual patient satisfaction

A robust pre assessment process where the patient can discuss their individual needs, coupled with the correct staffing at ward level contributes to the improving score.

Nottingham Woodthorpe Hospital has taken the following actions to improve the quality of its services by feedback regarding the patient’s experience is received through the following routes:

Patient satisfaction surveys We value your opinion questionnaire leaflet Direct verbal feedback to Ramsay staff. Internal Ramsay audit /inspection processes. CQC inspection feedback. Written feedback via letters/emails/complaints PROMs surveys. Annual PLACE patient audit


Venous thromboembolism (VTE)

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

5: Treating and caring for people in a safe environment and protecting them from avoidable harm

VTE Assessment: Period Period13/14 Q3 Several 100% NT244 63.2% Eng 95.8% 13/14 Q3 NVC40 95.0%13/14 Q4 Several 100% NT205 67.0% Eng 96.0% 13/14 Q4 NVC40 99.3%


Nottingham Woodthorpe Hospital considers that this data is as described for the following reasons

A robust patient assessment process coupled with the cooperation of all our Surgeons has ensured we can aim and reach full compliance thereby minimising the risk of VTE for patients.

Clostridium Difficile Infection

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.


C. Diff rate: Period Periodper 100,000 2012/13 Several 0 RNA 58.2 Eng 22.2 2012/13 NVC40 0.0

bed days 2013/14 Several 0 RVW 30.8 Eng 17.3 2013/14 NVC40 11.9




An annual strategy for Infection Prevention and Control (IPC) is developed at a corporate level by the Group IPC and policies are revised and redeployed every two years. IPC programmes are designed to bring about improvements in performance and practice.

A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and best clinical practice. Within the Nottingham Woodthorpe hospital we have infection control link nurses in all clinical areas ensuring that IPC management remains high priority throughout the hospital. Healthcare associated infections (HCAI) are acquired as a result of healthcare intervention. High standards of Infection Prevention and Control practice minimise the risk of occurrence of HCAIs.

Incident rate and patient safety

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death


Incident Rate: Period PeriodPatient Safety 2011/12 RP6 2.6 TAJ 84.4 Eng 13.5 2012/13 NVC40 6.72

2012/13 RRF 2.0 RAT 85.6 Eng 14.8 2013/14 NVC40 5.84



The senior management team ensure that incidents are investigated and when lessons are learned from these events they are shared with staff across the hospital so that we can prevent the same type of incidents happening again.


Every incident is reviewed by Matron and an investigation process, Root Cause Analysis and action plan implemented where appropriate. The RiskMan system immediately reports incidents directly to the Corporate Risk Management Team allowing the identification of trends at the Nottingham Woodthorpe Hospital and throughout the Ramsay organisation to further identify trends and outlying data. Locally all incidents are reported through Risk Management and Clinical Governance Committees.

Nottingham Woodthorpe Hospital has taken the following actions to improve the quality of its services, by:

Maintaining a robust staff induction and mandatory training programme Monthly Risk management and Clinical Governance meetings are

instigated where risk key performance indicators and incidents are discussed and disseminated

Effective implementation of the new falls risk assessment for all ward staff RiskMan introduction training updates via web based rolling programme

Friends and Family Test

Friends and Family Test – Patient. The data made available by National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2)

4: Ensuring that people have a positive experience of care This indicator is not a statutory requirement.


A NHS-wide ‘Friends and Family’ test to improve patient care and identify the best performing hospitals in England was announced in 2012 by the Prime Minister.

All patients at The Nottingham Woodthorpe hospital are routinely invited to take part in this anonymous survey. By completing a simple questionnaire asking whether they would recommend our hospital to their family and friends. Scores are published on the NHS Choices Website www.gov.uk


http://www.gov.uk/

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.

Never Events

SUIs: Period Best Worst Average Period Nottingham

(Severity 1 only)

Jul - Sep 12 NA NA NA 2012/13 NVC401.3%

Oct11 - Sep12

NA NA Eng 11,563 2013/14 NVC401.8%

Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. For further details please visit: http://www.nrls.npsa.nhs.uk/resources/collections/never-events

The core list of “never events” includes: Wrong site surgery Wrong implant/prosthesis Retained foreign object post procedure. Wrongly prepared high risk injectable medication Maladministration of a potassium containing solution. Wrong route administration of chemotherapy Wrong route administration of oral /enteral treatment Intravenous administration of epidural medication. Maladministration of insulin Overdose of midazolam during conscious sedation Opioid overdose of an opioid naive patient Inappropriate administration of daily oral methotrexate Transfusion of ABO incompatible blood components.


http://www.nrls.npsa.nhs.uk/resources/collections/never-events

Misplaced naso or oro-gastric tubes. Wrong gas administration. Failure to monitor and respond to oxygen saturation. Air embolism. Misidentification of patients

There was 1 Never Event at Nottingham Woodthorpe Hospital during 2013/14.

Never event: Orthopaedic –– Reported on 13th December 2013A patient underwent a right hip resurfacing operation at our hospital in September 2011 and was discharged home following an uneventful recovery. Patient then had a left hip resurfacing in August 2013 and at the Outpatient follow up appointment the pelvis X-Ray revealed a foreign body (screw shaped object) on right side. The Consultant initially thought this was an artefact (loose change etc) in the patients’ pocket but on closer examination of all x-rays taken since the original surgery in 2011 it revealed the object had always been present since the check x-ray performed 2 days post procedure.

The patient had been asymptomatic since 2011 and the foreign body had remained in the same position and as a result has not required surgical intervention and this was discussed in depth by the consultant.

A comprehensive investigation was undertaken to establish the root cause, actions and learning’s in order to prevent recurrence. The patient was fully informed; the incident was reported to Nottingham City CCG with STEIS notification. The incident was reported to Ramsay Central Clinical Governance Lead via the Ramsay’s RiskMan system and The Care Quality Commission was also notified of this incident as per policy and procedure.

3.2.1 Infection prevention and control

Nottingham Woodthorpe 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:

We chair bi-monthly infection control meetings with links to Microbiologists at Nottingham University Hospital NHS Trust. This is a proactive group with representation from all departments to ensure that each part of the patient’s pathway is safeguarded against the risks of infections. Hand washing is high on our agenda and in addition to regular staff training we are replacing all the hand washing gel units across the hospital with non-touch units to minimise the risk of cross infection. .

We report on a monthly basis on all aspects of infection control to our Clinical Effectiveness Committees and quarterly to the Medical Advisory Committee.

The graph shows a slight increase in the % of patient infections whilst still being a very low number of actual incidents of infection. Actions above have been implemented to address and halt this rise, with an anticipated reduction in the coming year.

2011/12 2012/13 2013/140

0.05

0.1

0.15

0.2

0.25

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 Nottingham Woodthorpe 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.

The PLACE audit for 2014 was undertaken on the 12 th and 16th May 2014 and submitted for inspection to the Health and Social Care Information Centre. The results will be available at the end of June 2014 but at the time of submission, the hospital still awaits the outcome.

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.

Each department maintains a register of risks which are review at least yearly or more often if incidents occur. A Corporate initiative has identified a number of Corporate-level risks to whish each facility is transcribing, updating and taking action on local risks to deliver a centralised Risk Register that can be monitored at both local and national levels.


3.3 Clinical effectiveness

Nottingham Woodthorpe 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 Returns 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

0.050.10.150.20.250.30.350.4

Return to Theatre Score


Retrnn to Theatre

(Percentage of Adm

issiosns)

The majority of Returns to Theatre were haematomas that were short-lived and did not present any issues of ongoing concern. Consultants are made aware and appropriate actions taken on a patient-by-patient basis.


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 Patient focus groups PROMs surveys Care pathways – patient are encouraged to read and participate in their plan

of care


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

Every patient is asked 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

40

60

80

100

91.5 91.0

Satisfaction ScoresNHS/Private Patients


Satisfaction Scores

We welcome feedback from patients regarding their experience Nottingham Woodthorpe hospital. We are grateful of the time our patients take to provide this information which is invaluable as it informs service development. We act promptly to address constructive comments and use positive feedback to re-enforce good performance.

Positive feedback is relayed to the relevant staff to reinforce good practice and behaviour and the management team ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. Our risk reporting system ‘RiskMan’ has the capacity to record feedback electronically against individual Consultants. This allows us to provide our Consultants with a report relevant to their practise.

Nottingham Woodthorpe hospital asks all patients to complete a ‘We Value Your Opinion’ leaflet to enable us to collate patient opinion and act immediately upon any concerns. As a direct result of the comments received from the ‘We Value


Your Opinion’ questionnaires the following are some examples of how we have improved care:

Staff and Consultant attitude – Customer Service Training has been provided where issues around staff attitude have been raised. Most concerns are around tone of communication rather than misinformation, and the training has seen some good outcomes

Clinical Care – Nottingham Woodthorpe Hospital has provided opportunities for external training, and internal Competency Training for all clinical staff where a shortfall in knowledge and/or skills has been identified

Facilities - where the facilities were negatively received, note has been taken and an improvement and upgrade programme implemented

Our Chefs regularly visit patients following admission to discuss and receive feedback on the quality of food and the options available. The catering team work closely with the ward hostess team to ensure a consistent service is delivered to a high standard.

Catering facilities refurbishment has taken place; including replacement of some equipment, both in the main kitchen area and the ward serveries. An addition upgrade of some kitchen equipment and full replacement of patient crockery has been actioned.

A full review of menu choice has been reviewed which was launched in April 2014. The new menu offers a greater choice to patients and in addition to this the new options are listed on an updated menu card.


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



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:

0115 920 9209

and

http://www.nottinghamhospital.co.uk/


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