Boston West Hospital. Quality Account 2013/14. Quality Accounts 2013/14 Page 1 of 52

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1 Boston West Hospital Quality Account 2013/14 Page 1 of 52

2 Contents Introduction Page Welcome to Ramsay Health Care UK 3 Introduction to our Quality Account 4 PART 1 STATEMENT ON QUALITY Statement from the General Manager Hospital accountability statement 7 PART Priorities for Improvement Review of clinical priorities 2013/14 (looking back) Clinical Priorities for 2014/15 (looking forward) Mandatory statements regarding quality of NHS services Review of Services Participation in Clinical Audit Participation in Research Goals agreed with Commissioners Statement from the Care Quality Commission Statement on Data Quality Stakeholders views on 2013/14 Quality Accounts 29 PART 3 REVIEW OF QUALITY PERFORMANCE The Core Quality Account indicators Patient Safety Clinical Effectiveness Patient Experience Case Study 47 Appendix 1 Services Covered by this Quality Account 49 Appendix 2 Clinical Audits 50 Appendix 3 Glossary 51 Page 2 of 52

3 Welcome to Ramsay Health Care UK Boston West 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) Page 3 of 52

4 Introduction to our Quality Account This Quality Account is Boston West 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. Page 4 of 52

5 Part Statement on quality from the General Manager Carl Cottam General Manager Boston West Hospital As the General Manager of Boston West Hospital I am passionate about ensuring that we deliver consistently high standards of care to all of our patients. Our Vision is that: As a committed team of professional individuals we aim to consistently deliver quality holistic care for all of our patients across a full range of care services. We believe we are able to achieve this by continually updating our key skills and knowledge enabling us to deliver evidence based clinical practice throughout the Hospital. Boston West Hospital is a recognised Centre of Excellence for the delivery of day case services. Our Quality Account details the actions that we have taken over the past year to ensure that our high standards in delivering patient care remain our focus for everything we do. Through our vigorous audit regime, and by listening to all our stakeholders, including patient feedback, we have been able to identify areas of good practice and where we can improve the care our patients receive. This has Page 5 of 52

6 enabled us to refine some of our processes which have resulted in making further improvements. To ensure that we deliver clinical excellence depends on the whole team. We have an excellent training and education plan which involves all members of our administrative and clinical teams. Every individual member of staff is crucial to the success of our hospital and we value the contribution that they make in delivering great customer care. Our Quality Account has been produced to provide information about how we monitor and evaluate the quality of the services that we deliver. We hope to be able to share with the reader our progressive achievements that have taken place over the past 2-3 years. Boston West Hospital has a very strong track record as a safe and responsible provider of health care services and we are proud to share our results. Our Quality Accounts have been developed with the involvement of our staff who have been instrumental in developing a systems approach to risk management, which focuses on making every effort to reduce the likelihood and consequence of an adverse event or outcome associated with treatment of a patient. To ensure a coordinated approach to the delivery of care for patients and to monitor the adherence to professional standards and legislative requirements the Clinical Governance Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and safety performance of the Hospital. These committees have reviewed and agree with the content and action details within these Quality Accounts. As the General Manager I am aware of all aspects of clinical quality and NHS services provided at Boston West Hospital and can confirm the accuracy of this document. If you would like to comment or provide me with feedback then please do contact me on carl.cottam@ramsayhealth.co.uk or telephone: Page 6 of 52

7 1.2 Hospital Accountability Statement To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate. Carl Cottam General Manager Boston West Hospital Ramsay Health Care UK This report has been reviewed and approved by: Medical Advisory Committee Chair: Mr. V. Csok Clinical Governance Committee Chair: Mr. M. Necas Regional Director, Midlands Region, Ramsay Health Care: Mr. James Beech The Patient & Public Involvement Forum Committee Members South Lincolnshire Clinical Commissioning Group Lincolnshire Health Watch Lincolnshire Health Overview and Scrutiny Committee Page 7 of 52

8 Welcome to Boston West Hospital Boston West Hospital is a purpose built facility which provides services for assessment, diagnosis and treatment of common medical conditions, and has a suite of outpatient and treatment rooms which has recently been refurbished to create an additional spacious consultation room. A well-equipped modern theatre undertakes a range of surgical procedures and endoscopic (diagnostic) investigations. Support services include a three stage Sterile Services Unit, which meets the stringent standards set by the Department of Health. The Hospital provides NHS and private day case facilities for the following specialties: Orthopaedic Ophthalmology General Surgery Pain Management Gynaecology Gastroenterology Urology Physiotherapy Cosmetic Surgery Our full list of services can be found in Appendix 1. Page 8 of 52

9 We provide safe, convenient, effective and high quality treatment for adult patients (excluding children below the age of 18 years), whether privately insured, self-pay, or from the NHS. A high percentage of our patients have come from the NHS sector, patients choosing to use our facility through Choose and Book. Our services help to ease the pressure on The Pilgrim NHS Hospital and Lincoln County Hospital and other local NHS facilities. We have worked closely with the Hospital Management Team and our NHS Clinical Commissioners, Lincolnshire South CCG, to ensure improved access for patients requiring day case surgery. We have close links with GP surgeries, providing information, training and liaison in order to monitor their needs and the requirement of the local population. We look forward to building strong relationships and working closely with all of the Lincolnshire Clinical Commissioning Groups (CCGs) During the past year 8628 patients have attended outpatient clinics at our hospital. We have treated a total of 2,595 day case surgical patients which is an increase of 382 on the previous year. Of those patients 2,487 (95.84%) were NHS patients, and 108 (4.16%) private insured and self pay patients. Boston West Hospital has a fully accredited Sterile Services Unit, compliant to the latest decontamination regulations and legislation. We currently employ the following staff at Boston West Hospital: 1 General Manager (covering 2 hospitals) 1 Matron / Clinical Lead 1 Administration / Bookings Manager 4 Receptionist / Administrators and 2 Medical Secretaries all of whom work part time 1 Liaison Officer 2 employed Consultants - a Consultant General Surgeon and a Consultant Anaesthetist. We also work with 26 consultants who have practicing privilege credentials with Ramsay, the majority of which also work at the local NHS trust. 6 Registered Nurses, 2 Operating Department Practitioners(ODP), and 3 Health Care Assistants Page 9 of 52

10 6 Sterile Services Technicians 3 Housekeeping Staff 1 Supplies / Maintenance Coordinator We also have a shared Accountant, Engineer, HR Coordinator, and Clinical Coder with another local Ramsay hospital We have a number of regular Bank Nursing, ODP, Sterile Services Technicians and Housekeeping Staff. A Consultant Anaesthetist is on site when the unit is in operation with patient procedures, along with a minimum of 1 Advanced Life Support (ALS) Trained Nurse We work in close partnership with commissioners to deliver day care surgery to the residents of Lincolnshire, and also with the Pilgrim Hospital, United Lincolnshire Hospital Trust (ULHT) utilising Radiology, Pathology and Occupational Health Services. We have agreements in place for the transfer of critically and non critically ill patients and for direct fast track transfer of patient care into the cancer networks. Patient engagement and involvement has been a high priority for the past year as we continue to keep patients at the heart of everything we do. Our Patient Group continues to develop and plays the valuable role of critical friend to the Hospital. In addition to conducting our recent PLACE assessment patients have been involved with our Disability Discrimination Act audit, and have undertaken a review of all patient communication including patient discharge information and the Hospital website to ensure that it is patient friendly. Patient feedback has become a real driver for improvement and the comments we receive both via internal evaluation We Value Your Opinion and external evaluation Family and Friends and NHS Choices are reviewed regularly by our Department Heads and the Hospitals Senior Management Team. The introduction of a new web based patient survey means that we are now able to gather even more valuable patient opinion and utilise this as we constantly strive to improve our services. Currently 97% of patients would recommend Boston West Hospital to family and friends. Page 10 of 52

11 Absolutely fabulous service, knowledgeable friendly staff, wonderful care. I will recommend you to everyone I know who needs any treatment and am looking forward to having my other eye done! V Timms - (Cataract patient 2013) In addition to patient involvement our Liaison Officer works closely with GP Practices, Opticians and communities across the county to ensure that both referrers and patients are aware of our services and that these services meet the needs of local people. During the past year we have developed a programme of free clinical education to support health professionals in their continued education and training. This has been well received by GPs, Optometrists and trainees and has also helped us strengthen relationships and improve communication between our Consultants and local clinicians. These educational sessions have been delivered by our Consultants, Clinical and Theatre leads at GP Practices throughout Lincolnshire and at the hospital itself. GPs have also attended outpatient clinics as observers to further increase their knowledge and understanding of certain specialities such as pain management. Boston West Hospital is approved by the General Optical Council as a provider of continued education and training (CET) enabling us to deliver accredited training to Optometrists, dispensing Opticians and support staff. The Ramsay Trainer explained the whole session with a full and thorough understanding of Choose and Book. Easy to understand and a very useful morning P Goodman - Westside Surgery Well presented and very informative, gave a clear idea as to how to deal with shoulder pain P Sharma GP Registrar Excellent and thorough presentation providing information for use in practice and when dealing with patients D Enderby Enderbys Opticians Page 11 of 52

12 We are always happy to showcase our hospital and this year have welcomed visits from patient and community groups, GP Practice staff, members of the Health Scrutiny Committee for Lincolnshire and Member of Parliament Mr Mark Simmonds pictured below with members of the Boston West Hospital Team. I was delighted to visit Boston West Hospital and meet with staff. Due to the introduction of Patient Choice, NHS patients can use this fantastic facility and take advantage of the great healthcare which is offered here. Mark Simmonds MP (Boston and Skegness) Boston West Hospital has participated in health road shows organised with partners all working within provision of health and wellbeing services along the local East coast where local people could come and find out more about the services we. We supported the Boston United Football Club Community Day, an event primarily promoting health and wellbeing through sport and activity but another good opportunity to engage with local people and promote patient choice. Page 12 of 52

13 We continue to work closely with partners and regularly invite health and wellbeing providers to display information relating to community services in our reception area and provide advice to patients, relatives and carers where appropriate. St Barnabas Hospice and Lincolnshire County Council Health Trainers are organisations which have found this to be useful and we feel it provides a holistic approach to our patient s long term wellbeing. Hospital Staff have been working together with patients to raise funds for charity. This year Pancreatic Cancer Care and Fenbank Greyhound Sanctuary were the chosen charities. Ramsay Health Care has donated resources and staff have volunteered time to arrange fundraising activities and raffles. Page 13 of 52

14 Patients tell us how important good customer service is to their experience of healthcare in our hospital. In response we have introduced a Customer Service Excellence programme (CSE) to encourage excellence in our staff and recognise members of the Boston West team who demonstrate excellent customer service. Staff who demonstrate exceptional care, attention and support can be nominated by patients, carers, visitors and colleagues and work their way to bronze, silver and the ultimate gold CSE award. To date members of our clinical, administration, housekeeping and sterile services departments have achieved bronze and in some cases silver awards and are working hard to achieve the gold. Page 14 of 52

15 Part Quality priorities for 2013/2014 Plan for 2013/14 On an annual cycle, Boston West Hospital develops an operational plan to set objectives for the year ahead. We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services. To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital. Priorities for improvement A review of clinical priorities 2013/14 (looking back) Dementia Screening We worked in collaboration with Clinical Commissioning Groups to adapt national CQUIN s to enable the hospital to participate in a national campaign. We were committed to a programme of identifying any patients over the age of 75 that displayed signs and symptoms of dementia and referred them to the appropriate care providers. This was undertaken by nurses that were trained specifically to identify patients with early signs of dementia as part of our pre-assessment service. Page 15 of 52

16 Patient Safety: Delivery of Compassionate Care Compassion in care delivery was a priority that was measured consistently throughout the year. A variety of different tools are used to measure effectiveness of care and these include patient feedback, complaints, inspections and daily observation from senior clinical staff. Lack of compassion was not a theme identified as part of internal governance complaint reviews. The hospital has had an unannounced CQC inspection, and a quality themed inspection, from Lincolnshire CCG as well as internal inspections and audits all of which confirm the quality of care provided was delivered to the required standards. PLACE Assessment - The Frances report reiterated the importance of monitoring healthcare practice through peer assessment. Our aspiration was not only take part in the PLACE inspection but to formulate a patient and public forum to inform and underpin the development of our service. The purpose of the PLACE assessment was to review cleanliness, catering, environment and the facilities provided. Our aim of developing a partnership through a forum allowed patients and public to influence change and engage with us about our practice and decision making. Clinical Standards: EWS One of the clinical standards for 2013/14 was linked to CQUIN and looked at the early warning system (EWS). EWS provides a structure within which nurses escalate concerns about deteriorating patients to reduce clinical risk. Clinical audit has demonstrated improved compliance and nurses have undergone comprehensive training to ensure they have the skills and underpinning knowledge to deliver safe and effective care. Clinical Effectiveness: Implementation of the Electronic Rostering System The hospital has successfully implemented an electronic rostering system that has improved efficiencies and enabled monitoring of safe staffing levels Clinical Priorities for 2014/15 (looking forward) Patient Experience Patient experience continues to be a key focus that underpins every priority at Boston West Hospital. Fostering an environment that enables us to learn from patient feedback is critical to the growth and development of our service. Patient Satisfaction The hospital utilised patient satisfaction data gathered by an external provider to identify areas for improvement. Having listened to our patients we then worked in collaboration with our clinical commissioning groups to identify CQUIN s that would monitor and measure improvement in service through Page 16 of 52

17 audit and patient satisfaction survey. The clinical priorities for 2014/15 will include focus on pain management and information about pain management at point of discharge. Friends & Family After the successful role out of day case friends and family our next priority is the implementation of the friends and family survey in the outpatient department Clinical Effectiveness It is important for the patients who choose to be treated by our clinicians that the procedures they undergo are effective and appropriate. We measure and record how effective we are publishing data to inform and benchmark. PROMS Patient related outcomes measures are a clinical priority for 2014/15 and we are focusing on improving our response rates for groin hernias and varicose veins. Patient outcome measures enable health care professionals to measure the overall benefit of undertaking surgical procedures and the clinical effectiveness of surgical procedures. Patient Safety It is important patients know that they are being cared for in a safe environment by staff that are appropriately trained. There is also a contractual requirement to demonstrate to the clinical commissioning groups that we achieve high standards of clinical safety. This is done through numerous audits, reports and inspections. VTE One of our clinical priorities for 2014/15 continues to be minimizing the number of VTE episodes by ensuring VTE risk assessments are completed on all patients. We also continue to monitor that we give prescribe and administer appropriate prophylaxis. All VTE episodes will have a full RCA investigation report completed and lessons learnt disseminated. Our aim is to ensure over 98% patients have a completed risk assessment and appropriate prophylaxis given, and 100% of VTE episodes have a full RCA completed within agreed time scales with the CCG and monitored through audit. EWS- CQUINs 2014/15 will include further training in relation and monitoring of the effectiveness of training. This will be required following after a review of the corporate early warning score resulted in changes being implemented to the scoring system as a result of new national guidelines. Page 17 of 52

18 Local / National CQUIN s 2014/15 Goal name Indicator name Indicator description Friends and Family Test Friends and Family Test Friends and Family Test Friends and Family Test - Early Implementation Friends and Family Test - Increased or maintained Response Rate Friends and Family Test - Increased Response Rate in inpatient (and daycase where applicable) services Early implementation Increased response rate at both sites for Ramsay Healthcare (Boston West Hospital Day case, Fitzwilliam Hospital Inpatient and Day case) Increased response rates at both sites for Ramsay Healthcare (Boston West Hospital Daycase, Fitzwilliam Hospital Inpatient and Daycase) NHS Safety Thermometer NHS Safety Thermometer - Improvement Goal Specification. Falls Maintenance of falls performance (6 month median to not deteriorate) Dementia Dementia - Find, Assess, Investigate and Refer The proportion of patients aged >75 admitted as an elective admission undergoing a face to face preassessment, the proportion of those identified as potentially having dementia who are appropriately assessed, and the number referred on to specialist services. Each patient admission can only be included once in each indicator but not necessarily in the same month, as the identification, assessment and referral stages may take place in different months. Dementia Dementia - Clinical Leadership Named lead clinician for dementia and appropriate training for staff Pain Management (Local CQUIN) Post Operative Pain Management The indicator sets out to improve pain management for all admitted patients, ensuring that patient s pain is scored using a nationally recognised pain scoring tool and that appropriate action is taken according to pain score each time a set of clinical observations is recorded. (Exceptions will include 1st stage recovery where the pain score is recorded as per Ramsay policy and not at 5 minute intervals alongside clinical observations) Page 18 of 52

19 Pain Management (Local CQUIN) Post discharge pain management The indicator sets to improve communication about pain management for all admitted patients, ensuring that all in patients have relevant and appropriate literature and advice on discharge Pain Management (Local CQUIN) Post discharge pain management - patient experience The indicator sets to improve communication about pain management for all admitted patients, ensuring that all in patients have relevant and appropriate literature and advice on discharge Early Warning Score EWS Compliance Reduce clinical risk by implementing further change to EWS chart incorporating national guidance into EWS chart, train staff on use of new charts and monitor compliance with escalation of deteriorating patient Page 19 of 52

20 2.2 Mandatory Statements The following section contains the mandatory statements common to all Quality Accounts as required by the regulations set out by the Department of Health Review of Services During 2013/14 Boston West Hospital provided 22 NHS services. Boston West 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 31 st March 14 represents 100 per cent of the total income generated from the provision of NHS services by Boston West Hospital for 1 April 2013 to 31 st March 14. 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 In 2013/14 our percentage of agency cost was 0% The expectation for 2014/15 is that we will continue to recruit to permanent positions and retain permanent staff as vacancies arise and to allow for the rise in patient through put to maintain the avoidance in need of agency use. Lost time was particularly high this year at 14.6%. Due to long term sickness, maternity, new employee induction time and training which all contributed to lost time. Staff costs as a percentage of net revenue were 19.05%. We continue to work with our Well Being Service to support employees both in the work place and as part of a structured return to work service. Page 20 of 52

21 The total skill mix calculation for Boston West Hospital was worked out by calculating all contracted hours for registered nurses and healthcare assistants. 65% of staff caring for patients is registered nurses. 35% of staff are health care assistants. Boston West Hospital provides an ongoing training program for staff and monitors compliance for various elements of mandatory training. This allows us to meet contractual obligations as well as ensuring staff are competent and confident to provide care. Each year staff take part in a satisfaction survey, the results of which are analyzed for common themes. The senior management team then devises a strategy for progression. Boston West Hospital provides an ongoing training program for staff and monitors compliance for various elements of mandatory training. This allows us to meet contractual obligations as well as ensuring staff are competent and confident to provide care. The senior management team then devises a strategy for progression. 2012/13 saw the implementation of an employee engagement group to drive forward change led by employees. There were no RIDDOR events recorded for Boston West Hospital during this period. Patient The number of complaints per 1000 hospital patient days equates to 0.03%. Themes and trends are monitored through the local clinical governance and medical advisory committee. Corporate Ramsay has an overarching view of governance and providing feedback and benchmarking information. The annual audit program is inclusive of infection control and prevention. There is a monthly program that addressing different areas of infection control and the audit results ranged from 83% to 100% from 2013 to The corporate audit program includes hand hygiene, isolation, peripheral venous cannula care bundles, urinary catheter care bundles, surgical site surveillance and infection and control environmental audits. Locally mattress audits and various other departmental auditing are undertaken. The lower scoring clinical audits carried out earlier in the year all showed significant improvement throughout the year with action planning put in place to resolve any of the issues highlighted. Page 21 of 52

22 Boston West Hospital utilises an external company to gather unbiased data with regards to patient satisfaction. We analyze this information on a quarterly basis and review the lowest scoring areas. An action plan is then drawn up to ensure that we address the areas of concern that patients have highlighted through this mechanism. In quarter four % of patients felt they were involved in decisions about discharge and 88.9% of patients felt staff did everything they could to control pain. To focus on and improve these scores we have chosen local CQUIN initiatives to measure our improvements of management of pain control during admission and in preparation for discharge. Scores for time to admission, information given about condition and cleanliness of room improved to 100%. Scores were maintained at 100% in 11 measures, with overall satisfaction maintaining 100%, and 100% patients would recommend the service to family and friends 100%. We saw a drop in the monthly response rate, therefore a drive to promote our external survey to encourage patients to leave feedback has been implemented. However, we have a very good return of we value your opinion internal patient satisfaction feedback and excellent response rate to the friends and family survey for admitted patients. We have a governance system in place to monitor all significant clinical events. During the period of 2013/14 our overall percentage for significant events was 0%. Readmissions are monitored for trends; all of the readmissions were successfully discharged home. In percentage terms, the readmissions equated to 0% of our inpatients. Quality Our annual workplace health and safety score was 98%, which is an improvement on the previous year. An action taken from the audit was to increase our recycled waste, putting systems in place to facilitate this and providing staff training to raise awareness and compliance. Page 22 of 52

23 2.2.2 Participation in clinical audit During 1 st April 2013 to 31 st March 2014, Boston West Hospital participated in one national clinical audit. The national clinical audits and national confidential enquiries that Boston West Hospital participated in, and for which data collection was completed during 1 st April 2013 to 31 st 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 Outcome Review Programme Elective surgery (National PROMs Programme) National Audit of Seizures in Hospitals (NASH) Severe sepsis & septic shock* Bowel cancer (NBOCAP) Head and neck oncology (DAHNO) Lung cancer (NLCA) Oesophago-gastric cancer (NAOGC) Acute coronary syndrome or Acute myocardial infarction (MINAP) Cardiac Rhythm Management (CRM) Congenital heart disease (Paediatric cardiac surgery) (CHD) Coronary angioplasty National Adult Cardiac Surgery Audit National Cardiac Arrest Audit (NCAA) Cases Submitted 102 Not enough patients Not enough patients N/A N/A N/A N/A Not enough patients N/A N/A N/A Not enough patients Not enough Page 23 of 52

24 patients National Heart Failure Audit National Vascular Registry* Pulmonary hypertension (Pulmonary Hypertension Audit) Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)* Diabetes (Paediatric) (NPDA) Inflammatory bowel disease (IBD)* National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme* Paediatric bronchiectasis* Rheumatoid and early inflammatory arthritis* Falls and Fragility Fractures Audit Programme (FFFAP) Sentinel Stroke National Audit Programme (SSNAP)* Child health clinical outcome review programme (CHR-UK)* Epilepsy 12 audit (Childhood Epilepsy) Moderate or severe asthma in children (care provided in emergency departments)* Paediatric asthma Paediatric fever* Paediatric intensive care (PICANet) N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A The most up to date PROM s data available from HSCIC is for the period March 2013 to December In that period we had 72 PROM s returns, with compliance being 81% for hernias and 67.7% for veins. The reports one national clinical audit from 1 st April 2013 to 31 st March 2014, are being reviewed by the Clinical Governance Committee and Boston West Hospital intends to take the following actions to improve the quality of healthcare provided; Improve processes around PROMs compliance and analyzing patient outcomes Page 24 of 52

25 Local Audits The reports of 70 local clinical audits from 1 April 2013 to 31 st March 2014 were reviewed by the Clinical Governance Committee to see what actions were required to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. Exceptions from audit findings are presented at clinical governance and the medically advisory committee. An example of some of the exceptions reported include a lack of evidence of the specific information leaflet given to patients about their procedure to ensure patients can give an informed written consent. Although evidence of written information is given, the detail of the leaflet was not evident. Sessions were held with the nursing staff to raise awareness of this requirement and folders of specialty specific leaflets made more readily available to consultants in the consultation rooms. Variance to pathway in nursing documentation not being completed 100% of the time in the perioperative phase, and in completing the signature list. This audit was repeated and compliance improved Participation in Research There were no patients recruited during 2013/14 to participate in research approved by a research ethics committee Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Boston West Hospital s income in from 1 st April 2013 to 31 st March 2014 was conditional on achieving quality improvement and innovation goals agreed by Boston West Hospital 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. Further details of the agreed goals for 2013/14 and for the following 12 month period are available below. Page 25 of 52

26 Local / National CQUIN s for Lincolnshire 2013/14 Goal name Indicator name Indicator description Friends and family FFT increased response rate increased response rate Friends and family FFT -improved performance on staff friends and family test Improved performance on staff friends and family test Dementia Dementia -find, assess, investigate and refer The proportion of patients aged 75 and over to whom case finding is applied following elective admission undergoing a face to face pre-assessment, the proportion of those identified as potentially having dementia who are appropriately assessed, and the number referred on to specialist services VTE VTE risk assessment % of all adult in-patients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool VTE VTE Root cause analyses The number of root cause analyses carried out on cases of hospital associated thrombosis Encouraging healthy lifestyles Encouraging healthy lifestyles Alcohol cessation 90% of NHS Patients seen at face to face preadmission with their alcohol status recorded and intervention offered to 99% those at risk Early warning scores EWS compliance Reduce clinical risk to patients by increasing compliance with Medical Early Warning Assessments protocols through delivery of training programme Page 26 of 52

27 2.2.5 Statements from the Care Quality Commission (CQC) Boston West Hospital is required to register with the Care Quality Commission and its current registration status on 31 st March is registered without conditions. Boston West Hospital has not participated in any special reviews or investigations by the CQC during the reporting period Data Quality It is important to have safe practice and process to underpin healthcare care. Without excellent data quality we are not able to deliver safe effective care or demonstrate that it is delivered. The annual audit program is inclusive of data quality ensuring that any issues are identified and addressed. It is important that VTE compliance is monitored and that data is entered correctly because this informs our practice and informs patients how safe our service is. This year a VTE post operative re assessment addition was added to operation notes. This prompts clinicians to review a patient s risk of clot post operatively in the event that their clinical condition has changed and the risk of clot has increased as a result. Boston West Hospital will be taking the following actions to improve data quality. Develop a local quarterly RAG rated report broken down by consultant demonstrating infection rates versus activity Monitor compliance of post operative VTE documentation by consultants Improve the processes around data collection and submission in relation to PROMS NHS Number and General Medical Practice Code Validity Boston West 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 for outpatient care and 0% for accident and emergency care (not undertaken at our hospital). Page 27 of 52

28 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 overall score for 2013/14 was 83% and was graded green (satisfactory). Clinical Coding Error Rate Boston West Hospital was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission. Page 28 of 52

29 2.2.7 Stakeholders Views on 2013/14 Quality Account NHS South Lincolnshire CCG Commentary for Ramsay Boston West Hospital Quality Account 2013/14 NHS South Lincolnshire CCG s main priority is to ensure that services are safe and of a high quality. The Boston West Hospital Quality Account highlights areas of service that demonstrate high quality care using the three key areas of effectiveness, safety and patient experience. As part of the national CQUIN for last year Boston West Hospital achieved the introduction of Dementia Screening of patients over the age of 75 and where necessary referred them on to appropriate care providers. The hospital used an innovative approach to the PLACE assessments which review cleanliness, catering, environment and the facilities provided, by empowering a patient and public forum to influence change and give feedback on practice. Further, to enhance patient safety, a priority for 2013/14 was the introduction of an early warning system (EWS) which provided a structure for nurses to escalate concerns about a patient if their condition should deteriorate. The focus on patient experience is welcomed by the CCG and the continued drive to roll out the Friends and Family test survey by the introduction of a new web based patient survey means to gather patient opinion. Currently 97% of patients would recommend Boston West Hospital to family and friends. South Lincolnshire CCG notes that Boston West Hospital is required to register with the Care Quality Commission and its current registration status on 31 March 2014 has no restrictions. The Care Quality Commission has not undertaken any enforcement action against Boston West Hospital since its registration. South Lincolnshire CCG can verify that Boston West Hospital has reported against all the mandated statements within the Quality Account where data is available. In terms of performance against the CQUIN scheme for 2013/14 Boston West Hospital fully achieved the following: Friends and Family Test NHS Safety Thermometer VTE Encouraging Healthy Lifestyles - Alcohol Cessation EWS Compliance There was partial achievement of: Dementia - Find, Assess, Investigate and Refer The CCG endorses the areas identified for improvement for 2014/15 and the associated initiatives as detailed within the Boston West Hospital Quality Account in particular the focus on pain management and information about pain management at point of discharge. The CCG notes that one of the CQUIN s this year will continue to maintain emphasis patient safety namely, VTE risk assessment and prevention. Page 29 of 52

30 The South Lincolnshire CCG CQUIN scheme for 2014/15 will consist of the following: Friends and Family Test Dementia Safety thermometer improvement goal falls Pain management National Early Warning Score NEWS Compliance South Lincolnshire CCG endorses the accuracy of the information presented within the Boston West Hospital Quality Account and the overall quality programme performance will be reviewed through the formal contract quality review process and triangulation through patient experience surveys. Healthwatch Lincolnshire tbc Health Scrutiny Committee for Lincolnshire HEALTH SCRUTINY COMMITTEE Statement on Boston West Hospital's Quality Account for 2013/14 FOR LINCOLNSHIRE This statement has been prepared by the Health Scrutiny Committee for Lincolnshire. Progress on Priorities for We are pleased with the progress by Boston West Hospital on its priorities for , in particular its participation in the dementia screening programme and the outcomes of the Patient-Led Assessment of the Care Environment. Priorities for We support Boston West Hospital's priorities for , and look forward to progress on these priorities leading to improvements in the patient experience and patient safety. Page 30 of 52

31 Engagement with the Health Scrutiny Committee Three members of Health Scrutiny Committee visited Boston West Hospital in 20 January They found the visit a positive experience and the member of the Committee who wrote the report of the visit said: "The hospital is a happy, clean, well run environment where I would feel very happy to receive treatment." The report is set out below: "Sue Harvey, the Matron, and Heather Emmerson, the Liaison Officer, gave us a guided tour of the hospital and explained that Ramsay Health Care had taken over the hospital from Capio, and changed the name last year to Boston West Hospital. Ramsay Health Care have hospitals in Australia, France and a sister hospital (The Fitzwilliam) in Peterborough, with others across England. They offer NHS-funded and private health care. Day Case only services are commissioned by the CCGs and NHS, 95% by the Choose and Book system. They offer consultant-delivered care, short waiting times (4 6 weeks), and a choice of time and date. All patients are assessed to make sure they are suitable for day case surgery. Not all patients are suitable. If necessary a patient could be transferred to Pilgrim Hospital for critical care one case in the past five years. Boston West mainly performs orthopaedic and ophthalmic surgery, but also offers some urology, gynaecology and pain management services. Boston West also provides General Surgery and Gastroenterology Services. MRI diagnostic imaging is on a Friday. Consulting Rooms Hand sanitisers are available and are used by staff and patients, outside every door. There are five outpatient consulting rooms and one nurse in attendance. Nurses room at end of corridor. Reasonably bright and comfortable, two of the five rooms have a window. The consultant and staff on duty seemed happy with the system. Autoclave (Sterilising Unit) Surgery Surgical items from both the Fitzwilliam and Boston West are sterilised on site. All items are scanned in and can be tracked from source. All items are sterilised, packed and then steamed at high temperature. Distributed back to source and good for up to a year if unopened. Page 31 of 52

32 patients per month receive services from the day hospital. Two admission bays. Surgery is on a rolling basis, patients arriving every half hour or so. Patient lockers accessible from two sides. There is one operating theatre, with full time anaesthetist in attendance. All procedures follow the NICE and day surgery guide lines. 2 bed recovery bay with one to one nursing. 45 minutes 1 hour in recovery bay, then into a recliner prior to leaving. 24 hour help line available once a patient has been discharged. A knee surgery patient: in by 7.30am, in theatre by 8am, home before 11am. Staffing Staff are recruited from the area. Staff are able to gain wide experience and progress within Ramsay Health. They have a customer excellence award system, Bronze, Silver and Gold, Assessment forms are given to patients, to help assess the patient journey. General Comments The hospital is a happy, clean, well run environment where I would feel very happy to receive treatment. There are well qualified experienced surgeons and staff." Achievements We congratulate Boston West Hospital on the following achievements during the last year: the high cleanliness rating from Patient-Led Assessments of the Care Environment; the absence of any MRSA infection the introduction of a new procedure in colo-rectal surgery; and the 97% patient satisfaction score. Conclusion We are grateful for the opportunity to make a statement on Boston West Hospital's Quality Account. We congratulate the Hospital on its improvements and achievements during the last year. The Committee would like to continue maintaining links with the Hospital during the coming year. Page 32 of 52

33 Patient and Public Involvement Group Representative Mr Joe Nash It is very difficult to write this without giving a too good to be true veneer. I am really impressed by everyone s friendly professional attitude and the personal service where one sees the same few people on every visit. I am involved with the patient participation group because Boston West Hospital asked me and the hospital does come across as genuinely wanting to give a service which is second to none. That can t be achieved without asking patients, people like me, for their input, ideas and suggestions for improvement. I am very happy to put my 18 years experience of poor health and as wheelchair user to some use. Whatever we do for a living, we know full well that after years of undertaking the same tasks we can get casual with some of the repetitive parts of our work. Health professionals are no different. The Ramsay staff however don t want to fall into that trap and we, the Patient Participation Group, are here to see the hospital though the patients eyes and keep patient perspective at the fore front of care at Boston West. I don t think that enough people are aware of patient choice and the fact they can choose to have NHS treatment at hospitals like Boston West which was why I was so pleased that the hospital Liaison Officer was happy to come out and talk to my stroke support group. Page 33 of 52

34 Part 3: Review of quality performance 2013/2014 Statements of quality delivery Matron, Sue Harvey Review of quality performance 1st April st 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 Page 34 of 52

35 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 Page 35 of 52

36 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 Mortality: Period Best Worst Average Period Boston West 2012/13 RKE 0.65 RXL 1.17 Eng /13 NVC /14 RKE 0.63 RBT 1.15 Eng /14 NVC27 0 Expected Period Best Worst Average Period Boston West Apr12 - Deaths: Mar13 RBA 0.1 RWH 44.0 Eng /13 NVC Jul12 - Jun13 RBA 0.0 RWH 44.1 Eng /14 NVC Boston West Hospital considers that this data is as described for the following reasons; Death is rare and as illustrated below the national average. Although there have never been any deaths at Boston West Hospital since the hospital opened 9 years ago. However, should any death occur, it would be investigated and reported the CQC and CCG. Page 36 of 52

37 PROMS PROMS: Period Best Worst Average Period Boston West Apr12 - Apr12 - NT NVC Eng Hernia Mar13 Mar13 NVC Apr13 - Apr13 - RTG RNA Eng Sep13 Sep13 NVC27 * PROMS: Period Best Worst Average Period Boston West Apr12 - Apr12 - RV NT Eng Veins Mar13 Mar13 NVC27 * Apr13 - Apr13 - RTD RLN Eng Sep13 Sep13 NVC27 * Boston West Hospital considers that this data is as described for the following reasons; Patient engagement Poor process Low volumes Boston West Hospital has taken the following actions to improve this; Redesigned the process Engaged and communicated with patients Weekly audit of the submissions Readmissions Period Best Worst Average Period Boston West 2010/11 RF4 0.0 RYR 15.8 Eng /13 NVC /12 RF4 0.0 RYR 15.8 Eng /14 NVC27 0 Boston West Hospital considers that this data is as described for the following reasons: Page 37 of 52

38 As a day case hospital, any unplanned emergency readmissions would present to the local Trust Hospital, therefore there are no readmissions as such to Boston West Hospital. We are aware of any readmission by the patient phoning the 24 hour emergency nurse helpline phone with a problem requiring the nurse to advise A&E attendance. These patients are then followed up to learn of the outcome. These known readmissions are reported on our Riskman incident reporting system and reviewed by our clinical governance committee. There have been 6 known readmissions in , which equates to 0.23%. This readmission rate is below average this could be attributed to good clinical care and treatment. Patients are provided with information at the point of discharge about after care services. Boston West Hospital will continue to provide patients with aftercare advice and encourage patients to return when clinically indicated. Responsiveness Responsiveness: Period Best Worst Average Period Boston West to personal 2011/12 RYR 73.3 RF Eng /13 NVC27 NA needs 2012/13 RYR 75.9 RJ Eng /14 NVC27 NA Boston West Hospital considers that this data is as described for the following reasons; The scores were taken from the CQC inpatient survey and therefore we were unable to participate in this survey due to being a day case surgery hospital. Feedback on responsiveness to patients needs is gathered from our external Qa Research survey and scores remain high. Scores of patient responsiveness for our CQUIN in 2012/13 were taken from 5 very similar questions in our external survey to those of the DoH inpatient survey, agreed with CCG commissioners. The scores ranged from 98% 100% Boston West Hospital will continue to listen and act upon patient feedback to maintain a high responsiveness to patient s needs. Page 38 of 52

39 VTE Assessment VTE Assessment: Period Best Worst Average Period Boston West 13/14 Q3 13/14 Q4 Several 100% NT % Eng 95.8% Several 100% NT % Eng 96.0% 13/14 Q3 13/14 Q4 NVC % NVC27 100% Boston West Hospital considers that this data is as described for the following reasons; The scores are higher than the national average The scores consistently improve year upon year Boston West Hospital has implemented VTE post operative re assessment of VTE risk to prompt clinicians post operatively. Any changes in risk as a result of surgery are documented and changes made to treatment accordingly. C. Diff rate C. Diff rate: Period Best Worst Average Period Boston West per 2012/13 Several 0 RNA 58.2 Eng /13 NVC ,000 bed days 2013/14 Several 0 RVW 30.8 Eng /14 NVC Boston West Hospital considers that this data is as described for the following reasons; The scores reflect consistent practice in pre assessment The scores reflect good infection and prevention control practices Boston West Hospital intends to continue its current practice to maintain a score of 0. Page 39 of 52

40 F&F Test F&F Test: Period Best Worst Average Period Boston West Jan-14 Several 100 RPA02 27 Eng /13 NVC Feb-14 Several 100 RPA02 18 Eng /14 NVC Boston West Hospital considers that this data is as described for the following reasons; The hospital places great emphasis on patient satisfaction and the friends and family question is encompassed within this. This is reflected in the score and Boston West Hospital has a higher than the national average scores as a result. Boston West Hospital intends to continue its good work and aim to increase its percentage further in 2014/ Patient Safety We are a progressive hospital and are 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 Infection prevention and control Boston West 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. Page 40 of 52

41 Infection Rates (percentage of Admissiosns) 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: Boston West Hospital has a dedicated Infection control nurse who is responsible for delivering an annual strategy of infection control. The annual plan is inclusive of a training, audit, surveillance and screening programme. The graph below illustrates a slight decrease in infection rates, this may be due to lessons learnt from infections and taking steps to avoid similar infections by implementing standardised antibiotic prophylaxis prescribing protocols for certain urological and general surgery procedure types. Infection is reported across all departments, including patients that present in the primary care. Infections are reported if there is a positive swab result or in the event of signs of an infection when a swab has not necessarily been taken. This is done through our surgical surveillance programme and ensures that we capture all data. 2.5 Infection Rates / / /14 Boston West Hospital Page 41 of 52

42 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 Boston West 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. In 2013 members of Boston West Hospital Patient & Public Involvement Forum Committee formed part of our PLACE inspection team, along with Heath Watch representation. Our results are illustrated below: Cleanliness Food Privacy, Dignity & Condition, Appearance & Wellbeing Maintenance 98.72% 60.00% 82.69% 95.75% 85.42% 88.90% 88.78% Green = National average Blue = Boston West Hospital score Page 42 of 52

43 Privacy and dignity was scored at 60% by the inspectors. This is due to a number of the measures being not applicable at Boston West Hospital with their being no overnight beds or patient bedrooms. In the measures that were applicable we scored well, apart from an issue that was highlighted regarding private conversations with patients in their admission bay / pod. We have a process in place to offer a private room for those conversations. We do not have catering facilities on site, so the food section was not applicable. There were a number of areas in need of touch up decoration. A planned maintenance programme is in place to ensure the areas highlighted will be subject to decoration over the months following our PLACE inspection. Staff have taken ownership of information boards in all areas to ensure they remain tidy and up to date 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; this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1,000 Admissions demonstrates the results of safety training and local safety initiatives. Period Best Worst Average Period Boston West 2011/12 RP6 2.6 TAJ 84.4 Eng /13 NVC /13 RRF 2.0 RAT 85.6 Eng /14 NVC Relative to the national average, Boston West Hospital is below the national average which is due to: 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. Local safety initiatives have included integration of dry mopping policy, increased awareness of how to report, and of review risk assessments. Page 43 of 52

44 Retrnn to Theatre (Percentage of Admissiosns) 3.3 Clinical effectiveness Boston West Hospital has a Clinical Governance team and committee that meet regularly through the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff feedback are systematically reviewed to determine any trend that requires further analysis or investigation. More importantly, recommendations for action and improvement are presented to hospital management and medical advisory committees to ensure results are visible and tied into actions required by the organisation as a whole Return to theatre 0.25 Return to Theatre Score / / /14 Boston West Hospital Ramsay is treating significantly higher numbers of patients every year as our services grow. The majority of our patients undergo planned surgical procedures and so monitoring numbers of patients that require a return to theatre for supplementary treatment is an important measure. Every surgical intervention carries a risk of complication, so some incidences of returns to theatre are normal. The value of the measurement is to detect trends that emerge in relation to a specific operation or specific surgical team. Our rate of return is very low; consistent with our track record of successful clinical outcomes. Page 44 of 52

45 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 Department of Health (DH) organisations 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 Manager whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/ s Patient focus groups PROM s surveys Care pathways patient are encouraged to read and participate in their plan of care 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 to 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 Page 45 of 52

46 Satisfaction Scores 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 Satisfaction Scores NHS/Private Patients / /14 Boston West Hospital As illustrated in the above graph our patient satisfaction scores remain very high. The activity at Boston West hospital has grown year on year and ensuring that we improve patient satisfaction scores is a key priority. An on- going in house training programme on customer service is delivered, and staff are recognised through a reward programme for exceptional levels of customer service. Page 46 of 52