Patient Safety & Quality Report 2015

Transcription

1 RAMSAY UNITED KINGDOM Patient Safety & Quality Report 2015 Overview Ramsay Health Care is committed to ongoing improvement of patient care in all areas. Ramsay Health Care has a strong commitment to safety and quality and this is reflected in our international and national organisation-wide approach to: Reviewing and improving on a continuous basis the performance of our patient safety and quality systems; Assisting our healthcare professionals and Visiting Medical Practitioners to monitor the safety and quality of care they provide; and Ensuring accountability for the safety and quality of care at all levels of our organisation right through to the Board of Ramsay Health Care. The Ramsay Health Care Board and Risk Management Committee endeavour at all times to fulfil their governance responsibilities by demonstrating strong strategic leadership in safety and quality, supporting Ramsay Health Care staff and employed and visiting medical practitioners in their efforts to provide safe, high quality care, and monitoring and responding to the performance of Ramsay s patient care systems in both inpatient and day patient settings. Scope Clinical governance framework; Clinical Indicators; Registration and accreditation; Patient Satisfaction; Performance and targets; Training and awareness; Audit, survey and assurance; Consumer Involvement; and Reporting and communications. Key Performance Indicators Our KPI s include: Maintaining registration with the Care Quality Commission (CQC) and meeting the Fundamental Standards of Quality and Safety; Performance against the national industry benchmarks and against internal benchmarks; and Compliance with patient safety and quality legislation, and standards. Achievements in Fiscal Year % of hospital and neurological rehabilitation facilities (34) are registered with the Care Quality Commission, are regulated and have achieved the Fundamental Standards of Quality and Safety. Participation in the pilot studies for the new Care Quality Commission inspection framework with 3 units having been assessed against the new Fundamental Standards of Quality and Safety using the new inspection framework, which has more assessors, takes place over a longer period of time, and includes experts by experience including service users and service deliverers. The success of 22 hospitals achieving JAG (Joint Advisory Group) accreditation for endoscopy services and the remaining 3 having dates for end of Short-listed for a Health Investor industry award for our Neurological Rehabilitation Services. A Registered Manager workshop was held for the Hospital General Managers and Matrons to update and review the Care Quality Commission operating model and judgement framework. PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 1

2 Setting up a national Theatre Managers Group to develop policies, processes and standard operating procedures for the whole of Ramsay Health Care UK. The regional decontamination facilities have achieved accreditation ISO 13485:2012; ISO 9001:2008 and MDD 93/42/EEC Annex 5. Ramsay Health Care continues to perform within the industry benchmark on all measured Patient Safety and Quality Indicators. Doctor revalidation process well embedded with 90% of doctors registered with Ramsay Health Care UK as their responsible body having their revalidation documentation signed off by the General Medical Council (GMC). PATIENT SAFETY & QUALITY INDICATORS Registered with Care Quality Commission RAMSAY PERFORMANCE (LATEST DATA AVAILABLE) All Ramsay Health Care UK hospitals are registered and regulated against national standards MOST RECENT INDUSTRY BENCHMARK (WHERE AVAILABLE) MRSA Bacteraemia rate per 100,000 bed days* PERIOD Nil MSSA Bacteraemia rate 1.23 per 100,000 bed days 1.4 per 100,000 bed days* E Coli Bacteraemia rate 0.41 per 100,000 bed days 6.45 per 100,000 bed days* C Difficile rate 0.82 per 100,000 bed days 3.12 per 100,000 bed days* Hand hygiene audit 95% nil January to April 2015 Patient Falls (All) 1.79 falls per 1000 bed days nil Patient falls (with injury from minor and above) Unplanned readmissions within 28 days 0.26 falls per 1000 bed days nil 0.17% of all admissions nil Unplanned return to theatre (all) 0.13% of all surgical admissions nil Medication safety errors Patients developing pressure ulcers whilst in hospital / facility (Grades 1 4) 0.19% patients experience a medication error 0.01% 4.7% (this figure is from all care settings including secondary care) nil Patient overall satisfaction 95% nil April June 2015 DETAILED PATIENT SAFETY & QUALITY PERFORMANCE RESULTS REGULATION AND ACCREDITATION All UK facilities are registered with the Care Quality Commission and regulated against the Fundamental Standards of Quality and Safety which were revised in 2014 and introduced in April 2015 in conjunction with the Health and Social Care Act 2008 (Regulated Activities) Regulations The fundamental standards mean everyone in England has a right to expect the following standards: Person-centred care Patients must have care or treatment that is individually tailored and meets the patient's needs and preferences. Dignity and respect Patients must be treated with dignity and respect at all times while they're receiving care and treatment. Consent Patients (or anybody legally acting on their behalf) must give consent before any care or treatment is given. * Commentary on annual data on MRSA, MSSA and E. coli bacteraemia and Clostridium difficile infection (April 2013 to March 2014) from Independent Sector Healthcare Organisations in England: Public Health England October 7th PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 2

3 Safety Patients must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Ramsay Health Care must assess the risks to patient s health and safety during any care or treatment and make sure our staff have the qualifications, competence, skills and experience to keep patients safe. Safeguarding from abuse Patients must not suffer any form of abuse or improper treatment while receiving care. Food and drink Patients must have enough to eat and drink to keep them in good health while they receive care and treatment. Premises and equipment The places where patients receive care and treatment and the equipment used in it must be clean, suitable and looked after properly. The equipment used in care and treatment must also be secure and used properly. Complaints Patients must be able to complain about your care and treatment. Ramsay Health Care must have a system in place so we can handle and respond to a complaint. Good governance Ramsay Health care must have plans that ensure we can meet these standards. Staffing Ramsay Health Care must have enough suitably qualified, competent and experienced staff to make sure we can meet these standards. Fit and proper staff Ramsay Health Care must only employ people who can provide care and treatment appropriate to their role. We must have strong recruitment procedures in place and carry out relevant checks such as on applicants' criminal records and work history. Duty of candour Ramsay Health Care must be open and transparent with patients about care and treatment. Should something go wrong, we must tell the patient what has happened, provide support and apologise. Display of ratings Ramsay Health Care must display our CQC rating in a place where patients can see it and include it on our website. The Care Quality Commission regulates the health care sector by asking 5 key questions about the service and the care it provides: Is it safe? Is it effective? Is it responsive? Is it caring? Is it well-led? Regulation and accreditation are important drivers for safety and quality improvement. Ramsay Health Care UK is a member of Private Healthcare Information Network (PHIN) and contributes activity and quality data to this forum. Ramsay Health Care UK is working with PHIN to increase data transparency across the independent health care sector and ensure patients are better informed about outcomes and quality of care before they use one of our facilities. DETAILED PATIENT SAFETY & QUALITY PERFORMANCE RESULTS CLINICAL GOVERNANCE STANDARD KEY PERFORMANCE INDICATORS All UK facilities are regulated by the Care Quality Commission against the Fundamental Standards of Quality and Safety. Ramsay Health Care UK has a clinical governance framework in place within an organisational risk management framework to monitor and assess those standards. Clinical Governance is an important driver for safety and quality improvement. Through clinical governance monitoring, Ramsay Health Care has been able to assess our level of performance, benchmarking our hospitals against each other and in relation to established national benchmarks enabling us to implement ways to continuously improve our service delivery to patients. Hand Hygiene RHC Internal Audit Rate: 95% Hand hygiene is conducted in accordance with the five moments that is: before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient s environment. Ramsay hospitals participate in the national hand hygiene strategy through Public Health England and through PLACE (Patient Led Assessments of the Care Environment) audits. Hand hygiene audits are conducted four times per year. Visitors to Ramsay facilities are encouraged through appropriate signage to wash their hands and use antiseptic hand rub located throughout Ramsay Health Care facilities. PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 3

4 Infection Rate The following infections (MRSA, MSSA, C Diff, E Coli) are all voluntarily reportable to Public Health England (PHE) and are measured nationally to enable a national health strategy to be developed. Ramsay Health Care UK individual facilities report in line with the reporting programme. Meticillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia There have been no incidences of MRSA bacteraemia in Ramsay Health Care UK facilities in 2014 Escheria Coli (E Coli) Bacteraemia There has been 1 case of E Coli bacteraemia in Ramsay Health Care UK giving a rate of 0.41 per 100,000 bed days there is no national hospital apportioned figure and the Independent Sector Hospital rate is 6.45 per 100,000 bed days compared to a national rate of UK hospital apportioned MRSA bacteraemia in Q of 0.87 per 100,000 bed days and the Independent Sector Hospital rate of 0.48 per 100,000 bed days in Q Hospital acquired Clostridium Difficile (C. Diff) There have been 2 cases of C Diff in Ramsay Health Care UK facilities giving a rate of 0.82 per 100,000 bed days Compared to the national hospital apportioned C Difficile rate of per 100,000 bed days 1 in Q and the Independent Sector Hospital rate of 3.12 per 100,000 bed days. Meticillin Sensitive Staphylococcus Aureus (MSSA) Bacteraemia There have been 3 cases of MSSA bacteraemia in Ramsay Health Care UK facilities giving a rate of 1.23 per 100,000 bed days compared to a national rate of UK hospital apportioned MSSA bacteraemia in Q of 8.01 per 100,000 bed days 1 and the Independent Sector Hospital rate of 1.4 per 100,000 bed days Patient Falls RHC Rate: 1.79 falls per 1000 bed days. RHC Rate of falls with some level of injury sustained: 0.26 falls per 1000 bed days The risk of falling increases according to age with data suggesting that one third of people over the age of 65 years have one or more falls a year. The data within Ramsay Health Care UK indicates that of all patient related falls on our sites over 70% are recorded within the over 65 age 1 Public Health England Quarterly Epidemiological Commentary: Mandatory MRSA, MSSA and E. coli bacteraemia, and C. difficile infection data (up to July - Sept 2014). PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 4

5 group of patients. It should also be noted that the data includes falls in residents at our Neurological rehabilitation centres where there is an increased risk of residents falling due to their conditions. Not all falls result in injuries, however, falls-related injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries may result in hospitalisation or an increased length of stay in hospital. The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medications and walking in unsafe footwear or slippers. The Ramsay Health Care falls prevention program targets those patients and residents who we identify as being at risk. We use specific criteria and tools to risk assess our patients and residents and then put in place a number of strategies to minimise falls whilst in hospital or neurological rehabilitation. We do this by educating our staff to ensure that the patient s call button and personal items are in reach; that call bells are attended to promptly; that patients are assisted to the toilet at regular intervals; and that patients have the appropriate walking aids. Some hospitals provide special footwear. Unplanned readmissions RHC Rate: 0.17% of all patients have an unplanned readmission within 28 days. Ramsay has a low percentage of patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge planning processes. Unplanned return to theatre RHC Rate: 0.13% of all surgical admissions have an unplanned return to theatre. Ramsay Health Care monitors any unplanned return to the operating theatre. Each hospital reviews the data collected to identify if any action is required. A low rate of return to theatre is desired, however sometimes a return to theatre is unavoidable and can be a life-saving measure. Patients may have an unplanned return to theatre for a number of reasons, including bleeding, a collection of blood (haematoma), infection, dislocation of a joint following insertion of a prosthesis, or investigation of symptoms. Medication Safety RHC Rate: 0.19% of patient admissions experience a medication error. No national benchmark is currently available. Medicines are used to both treat patients and prevent infections in the healthcare setting. It is important to measure the risk of errors and use of antibiotics and other drugs. Ramsay Health Care UK has a low rate of medication errors per patient admission. Antibiotic use is monitored by using an annual point prevalence survey which is aligned to Public Health England s survey. Based on this survey 60% of Ramsay patients receive antibiotics of which 9 out of 10 are for surgical prophylaxis. In addition, a pocket guide to prevent the incorrect prescribing and administration of penicillin (and related antibiotics) to patients with a recorded allergy has been developed and distributed to the clinical teams in NHS England has introduced a patient safety program and the Ramsay Group Chief Pharmacist is an active member of the Medicine Safety Officer team working closely with NHS England to share best practice and highlight potential risks in medication safety when they arise. Ramsay also reports medicine incidents which required medical intervention to the MHRA (Medicines and Healthcare products Review Agency) and NRLS (National Reporting and Learning System) and this information is used to improve safety nationwide. Ramsay Health Care UK ensures all national patient safety alerts are implemented, including the use of colour coded ports and connections to prevent the incorrect route being used to administer medicines. These alerts are supported by medicine management policies and standard operating procedures which adhere to UK best practice. Incidents are actively encouraged to be reported and all incidents are investigated and any learning shared across the business. Incidents are monitored by the company s Drugs and Therapeutics Committee and reported to the Clinical Governance Committee. Pressure ulcers RHC Rate: 0.01% per patient/resident admission Pressure ulcers are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and can cause significant pain and discomfort which may result in a slower recovery for the patient. Ramsay Health Care facilities are well equipped with the latest equipment to assist staff to prevent these injuries from occurring. Patients and residents are risk-assessed on admission using an evidenced based tool. Staff follow a care plan which is targeted to minimising a patient s risk of developing a pressure injury for those patients assessed as high risk. This includes inspecting the patient s/resident s skin frequently, managing moisture, keeping the skin dry, optimising nutrition and hydration and moving the patient or resident frequently or using special pressure relieving mattresses when needed. PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 5

6 Patient Satisfaction RHC Rate: 95% satisfaction Ramsay Health Care receives feedback from our consumers in a number of ways. The Patient Satisfaction Tracker is in the form of an online survey supported by a telephone survey. The survey is carried out by QA Research on behalf of Ramsay Health Care UK. In addition all NHS patients are invited to complete the Family and Friends Survey which is a government initiative and Ramsay Health Care UK has undertaken a separate patient satisfaction survey at the request of the Care Quality Commission. The results are fed back monthly and consolidated quarterly. The most recent results are April - June The response rate was over 33.6% compared to the previous quarter of 38.5%. It should be noted that in 2015 the tracker was expanded to include additional departments including outpatients which means robust comparisons to response rates from prior year cannot be made. Overall 95% of customers were satisfied with their care. This is a similar result as prior year. Only 1.4% of patients were dissatisfied with their care, a decrease of 0.4%. 95.7% of patients were likely to recommend us to their family and friends. This is the same result as the prior year. Only 1.9% would not recommend us, an increase of 0.4%. The highest compliance levels were recorded for: Were you given enough privacy when being examined or treated? 99.6% Do you feel that you were treated with respect and dignity while you were in the hospital? 99.3% When you had important questions to ask a nurse, did you get answers that you could understand? 98.9% On arrival at the Ramsay Health Care hospital or treatment centre, did you receive a friendly welcome? 98.4% When you had important questions to ask a doctor, did you get answers that you could understand? 98.4% It should be noted that the independent sector in the UK (of which Ramsay Health Care UK is a part) has a Friends and Family Test average score of 99 for those patients who are likely or extremely likely to recommend a hospital; compared to the average NHS score of 94. Of the hospitals in the UK scoring 100% for extremely likely to recommend, Euxton Hall was one of those. 9 Ramsay Health Care UK hospitals scored 100% likely to recommend - Bodmin, Euxton Hall, Mount Stuart, Duchy, Winfield, West Midlands, Berkshire Independent, North Downs and Horton. Major Initiatives Control Of Substances Hazardous to Health (COSHH) Training for all HODS Safety Sharp Implementation Occupational Health Surveillance screen Online System CASE STUDY 1 Surgical Safety Checklist In 2014 the Ramsay Surgical Safety Checklist (based on the initiative from the World Health Organisation) has been reviewed and revised to take into account lessons learned from some of the never events that have happened in the health care industry in the UK. Procedure specific checklists have been introduced and many hospitals have introduced a white board in theatre that is specially prepared to record checks and safety information. A DVD has been produced in the Horton Hospital to demonstrate the safe practices in using the WHO Safer Surgery checklist, and has been rolled out to all units who all have copies they use with their staff. CASE STUDY 2 Clinical Update for Clinical Staff In 2014 the corporate clinical team have continued to improve and expand the written clinical update for staff. This is a monthly update and placed on the intranet for all staff to access. It reviews lessons learned from incidents and adverse events and shares them with all staff they may affect. It also highlights changes in legislation and policy to ensure information reaches care staff in a timely way. This helps to improve and develop care delivery in all Ramsay Hospitals, improving safety and quality. 3 Private Healthcare Information Network PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 6

7 CASE STUDY 3 Internal Assurance Visit to all Ramsay Health Care UK facilities In 2014 the corporate based clinical team have worked with clinical staff in hospitals, General Managers and Regional and Executive Directors to develop an assessment framework and tool, based on the new CQC Fundamental Standards of Quality and Safety, and the 5 assessment domains (Safety, Responsive, Effective, Caring and Well-led) which will be introduced to the Independent Sector in 2015 when the new regulations (the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) come into effect on 1st April The team have piloted the tool, which enables Ramsay Health Care UK to closely monitor the standard of safety and care delivery in all its registered facilities. To date 6 facilities have been inspected with the rest to be completed by July This will increase the quality assurance and enable focussed improvement action plans to be implemented. PATIENT SAFETY & QUALITY REPORT 2015 / PAGE 7 RHC UK Patient Safety & Quality Report - July 2015