Renacres Hospital. Quality Account 2014/15

Transcription

1 Renacres Hospital Quality Account 2014/15

2 Contents Introduction 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 Priorities for Improvement Review of clinical priorities 2014/15 (looking back) Clinical Priorities for 2015/16 (looking forward) 2.2 Mandatory statements relating to the quality of NHS services provided Review of Services Participation in Clinical Audit Participation in Research Goals agreed with Commissioners Statement from the Care Quality Commission Statement on Data Quality Stakeholder s views on Renacres Hospital 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 Patient Feedback Appendix 1 Services Covered by this Quality Account Appendix 2 Clinical Audits

3 Welcome to Ramsay Health Care UK Renacres 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. The provision of high quality patient care is and will always be the highest priority of Ramsay Health Care UK. Of course our team of clinical staff and consultants are very much at the forefront of achieving this but there is also very much an organisation wide commitment to ensure that we continue to improve out outcomes every day, week, month and year. Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot be the responsibility of just a few, it takes all of us to be responsible and accountable for our performance in the various roles we all play. Having an organisational culture that puts the patient at the centre of everything we do is key to ensuring we enable everyone to perform at their peak to attain great outcomes. Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends, we will continue to strive to get ever better. I am very proud of our long standing and major provider of healthcare services across the world and of our Ramsay very strong track record as a safe and responsible healthcare provider. It gives us pleasure to share our results with you. Mark Page Chief Executive officer Ramsay Health Care UK Page 3 of 35

4 Introduction to our Quality Account This Quality Account is Renacres Hospital 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 35

5 Part Statement on quality from the General Manager Renacres Hospital is committed to being a leading provider of outpatient, diagnostic, day case and in-patient services by delivering high quality outcomes and an excellent patient experience. Renacres Hospital has become an integral part of NHS healthcare provision in Lancashire, particularly since its participation in delivering the E05 Cumbria and Lancashire Phase II Elective Surgery Agreement, which was in place Today the hospital continues to deliver high quality care under contract with the local Clinical Commissioning Groups and a key reason for the hospital s continued role in local NHS healthcare provision is the high standard of care provided. Ramsay Health Care UK has an organisational culture that puts the patient at the centre of everything we do. As General Manager of Renacres Hospital, I am passionate about ensuring that high quality patient care is our number one priority. This relies not only on excellent medical and clinical delivery but also upon continued commitment to driving improvement in clinical outcomes. Ramsay Health Care UK has a structured clinical governance framework that enables continual review of performance. This allows us to drive improvements for the benefit of all patients. Margaret-Ann Worrell General Manager, Renacres Hospital Page 5 of 35

6 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. Margaret-Ann Worrell General Manager, Renacres Hospital This report has been reviewed and approved by: Chorley and South Ribble Clinical Commissioning Group Simon Jones, Consultant Surgeon and Chair Medical Advisory Committee, Renacres Hospital Helen White, Regional Director Page 6 of 35

7 Welcome to Renacres Hospital Renacres Hospital is located near Southport, close to the M58 and M6. The hospital opened in 1987 and currently has twenty three single rooms all with ensuite facilities and two three chaired rooms for ambulatory patients. Renacres Hospital provides fast, convenient, effective and high quality treatment for patients of all ages (excluding children) whether medically insured, self funding or from the NHS. The Hospital offers a comprehensive range of treatments and services including ENT procedures, Maxillofacial and Dental surgery, Plastic surgery, Gynaecology, General Surgery, Orthopaedics and Urological procedures. Diagnostic facilities include contrast studies, barium studies, ultrasound, MRI and CT, in addition to general radiology. All of the Hospital s consultants are highly experienced and have patient care and comfort as their highest priority. All patients have the reassurance that a resident doctor is available 24 hours/day. Our physiotherapy clinic is staffed with chartered, HPC registered physiotherapists. Renacres Hospital has two out-patient outreach services based at The Village Surgery, Formby and Birleywood Surgery, Skelmersdale. Renacres Hospital is part of the Cheshire and Mersey Critical Care Network and has a Service Level Agreement in place for emergency transfer of critically ill patients. Renacres Hospital supports local charities and other groups. Last year we supported Queenscourt Hospice. Page 7 of 35

8 Part Quality priorities for 2014/2015 Plan for 2014/15 On an annual cycle, Renacres 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 Hospital s Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital. Page 8 of 35

9 Priorities for improvement A review of clinical priorities 2014/15 (looking back) PLACE The annual PLACE audit is a patient led audit with an assessment team that consists of 50% patients. The audit includes all internal and external areas of the hospital only excluding operating theatres. The audit is divided by each department of the hospital and assesses the standard of cleanliness and general upkeep of the building and grounds. It will also evaluate the standard of the food being served to patients, ensuring that all dietary requirements are met. The scoring system employs a system whereby areas are given a Pass, Fail or Qualified Pass. Renacres Hospital PLACE audit took place in April 2014 and the following is an overview of the scores achieved: Cleanliness 98.09% Food 92.9% Privacy 86% Condition 96.12% Public bodies including; The Care Quality Commission, The NHS Commissioning Board and The Department of Health use information from the PLACE assessments to ensure that all patients are given a high quality service. JAG Accreditation. In June 2014 the hospital s Endoscopy Unit underwent the JAG Accreditation visit and achieved a pass. Clinical Documentation Audits - Remained a priority in all areas with a corporate Ramsay focus set for 2014/15 on theatre safety checks and Physiotherapy documentation checks. The team achieved full completion of the Ramsay Corporate Audit Programme in the relevant timeframes. Page 9 of 35

10 Local CQUINS Equality Deliver System Self-Assessment Advancing Quality Hip and Knee Replacement Patient Reported Outcome Measures (PROMs) National CQUINS Friends and Family Test Safety Thermometer Clinical Priorities for 2015/16 (looking forward) Patient Safety Safety Thermometer. The Safety Thermometer focuses on the reduction of patient harm. The power of the NHS Safety Thermometer lies in allowing frontline teams to measure how safe their services are and to deliver improvement locally. The data can also be aggregated to measure improvement at a regional and national level. The Safety Thermometer is a national CQUIN indicator and in 2014/15 Renacres Hospital achieved its CQUIN target. Surgical Safety Checklist Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented as standard practice. Monthly audits will continue to be undertaken with an expectation of 100% compliance. Where this is not achieved actions plans will be developed and responsibilities communicated with the teams. Briefing and debriefing sessions after all operating sessions continue and give opportunity for shared learning, recommendations for future practice and aim to encourage autonomy for all members of the team. Compliance will be monitored by regular audit and reviewed by the hospital s Clinical Governance and Medical Advisory Committees. VTE Assessment - A VTE risk assessment is completed for patients according to CM 001 VTE policy and requires consultants to review and to complete prior to procedure. This remains a focus at Renacres Hospital with quarterly audits completed to maintain standards. Results are reviewed and actions determined at the hospital s Clinical Governance and Medical Advisory Committees. Page 10 of 35

11 Clinical Effectiveness Sepsis. A new local CQUIN has been introduced relating to sepsis. The aim is to ensure that clinical staff at Ramsay are aware of the early signs of Sepsis and to implement the Sepsis 6 pathway. The CQUIN also aims to ensure that patients and carers are made aware of the early signs of Sepsis and the correct action to take. Patient Experience Friends and Family Test. The Friends and Family Test aims to improve the experience of patients in line with Domain 4 of the NHS Outcomes Framework. The Friends and Family Test will provide timely, granular feedback from patients about their experience. In the first six months of use, the Friends and Family test gathered almost one million responses; by contrast, in the 2012 inpatient survey, 64,500 patients were asked for feedback. Commissioners should be assured that NHS providers have plans in place to reduce the proportion of people reporting a poor experience of care in line with the locally set level of ambition. In 2015/16 the friends and family test will continue to include in-patients, day cases and out-patients as a national CQUIN. Patient Satisfaction Survey. We will continue to encourage patients to provide feedback using our web based satisfaction survey. Hot alerts received following completion of the survey will be reviewed by the General Manger and Clinical Lead and action taken where there are areas identified for improvement. All comments positive and negative are shared with the whole team along with a monthly patient satisfaction dashboard. Compliments and complaints are reviewed at the hospital s Clinical Governance and Medical Advisory Committees and lessons shared with the nursing teams. We will continue to monitor posts on NHS choices and remain committed to retaining our five star recommendation. We have added to current patient feedback mechanisms by introducing a patient focus group and including patients in hospital PLACE audits. Advancing Quality. This initiative is aimed at improving the quality of care and patient experience. It is a local CQUIN where Renacres Hospital submits data regarding DVT and antibiotic prophylaxis. Compliance with completion of data is expected at 95% and at 80% completion via external audit and an ACS score of 95%. Reducing Health Inequalities. Elaborating on last year s local CQUIN Equality Delivery Systems, the Reducing Health Inequalities focuses on 2 key areas: Page 11 of 35

12 Better Health Outcomes. By auditing patient outcomes total health gain will be reviewed for elective procedures, specifically for those individuals who identify with a protected characteristic. Following analysis actions will be implemented with changes made to services, including any reasonable adjustments that have improved health outcomes for patients, specifically those with protected characteristics. Improved patient access and experience. The purpose of this CQUIN indicator is to monitor that patients carers and communities can readily access services and that they are not be denied access on unreasonable grounds and involved with decisions about their care. Patient Enquiry Phone Calls. The aim of this local CQUIN is to reduce the number of phone call and to utilise the tacit knowledge within frontline staff to improve patient care. Patient Reported Outcome Measures Studies (PROMS). We will continue to monitor patient response rates for those patients who have undergone hip and knee joint replacement surgery and inguinal hernia repair. Page 12 of 35

13 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 2014/15 Renacres Hospital provided NHS services across eight surgical specialties. Renacres 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 st April 2014 to 31 st March 2015 represents 100% per cent of the total income generated from the provision of NHS services by Renacres Hospital for 1 st April 2014 to 31 st March 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. Page 13 of 35

14 In the period for 2014/15, the indicators on the scorecard which affect patient safety and quality were: Human Resources Staff Cost % Net Revenue % HCA Hours as % of Total Nursing 19.3% Ward Hours PPD 6.1 Appraisal % - 100% Mandatory Training % - 100% Staff Satisfaction Score Number of Significant Staff Injuries - 0 Patient Formal Complaints per 1000 HPD's - 0 Patient Satisfaction Score 96.7% Total patient incidents per 1000 HPD s Readmission per 1000 HPDs 0.01 Quality Workplace Health & Safety Score - 99% Infection Control Audit Score 95.25%(ytd) Participation in clinical audit During 1 April 2014 to 31st March 2015, the hospital participated in both local and national audits. Page 14 of 35

15 The national clinical audits and national confidential enquiries that Renacres Hospital participated in, and for which data collection was completed during 1 April 2014 to 31st March 2015, 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 National Joint Registry (NJR) Elective surgery (National PROMs Programme) % cases submitted 100% Small volumes The reports of 2 national clinical audits from 1 April 2014 to 31st March 2015 were reviewed by the Clinical Governance Committee and Renacres Hospital had no actions to take as a result of these audits. Local Audits The reports of 79 local clinical audits from 1 April 2014 to 31 st March 2015were reviewed by the Clinical Governance Committee and Renacres Hospital intends to take the following actions to improve the quality of healthcare provided: Nutrition and Hydration Audit. Issue relating to full completion of fluid balance chart was identified and training arranged accordingly. In addition there has been an increased focus on ensuring the nursing staff document that patients have been offered fluids if the time to theatre is greater than 2 hours. Theatre Anaesthetic Audit. Issue identified that certain consultants were not completing full documentation. This has been addressed through the Local Clinical Governance Committee and ratified at the Medical Advisory Committee (MAC). The issue continues to be monitored and individual consultants written to by the MAC Chair. The clinical audit schedule can be found in Appendix 2. Page 15 of 35

16 2.2.3 Participation in Research There were no patients recruited during 2014/15 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 income from 1 April 2014 to 31st March 2015 was conditional on achieving quality improvement and innovation goals agreed between Renacres Hospital and the Clinical Lead of the Lead Commissioner for the CCG, through the Commissioning for Quality and Innovation payment framework Statements from the Care Quality Commission (CQC) Renacres Hospital continues with its current registration, without conditions, with the Care Quality Commission. The most recent inspection was carried out on 5 th November Renacres Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. Page 16 of 35

17 2.2.6 Data Quality Data Quality Statements NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2014/15 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: The patient s valid NHS number: 99.97% for admitted patient care; 99.96% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2014/5 was 75% and was graded green (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: Clinical coding error rate Renacres Hospital underwent an internal clinical coding audit in November The unit attained a score of 92.8% for primary diagnosis accuracy, 91.2% for secondary diagnosis, 96.4% for primary procedure and 97.8% for secondary procedure accuracy/completeness. The hospital continues to take the following actions to improve data quality: Regular training to ensure staff understand importance of accurate data input and have sufficient technical competence Employment of clinical coder to improve accuracy of recording Supporting national projects to ensure data accuracy Page 17 of 35

18 2.2.7 Stakeholder s views on Renacres Hospital NHS Greater Preston Clinical Commissioning Group: Page 18 of 35

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21 Part 3: Review of quality performance 2013/2014 Review of quality performance 1st April st March 2014 Introduction This publication marks the sixth 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. Vivienne Heckford Director of Clinical Services Ramsay Health Care UK Page 21 of 35

22 Ramsay Clinical Governance Framework 2015 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 Page 22 of 35

23 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. Page 23 of 35

24 3.1 The Core Quality Account indicators National Mortality Rates: Renacres Hospital: SHMI Figures are not available for Independent Sector Hospitals. Inferred average mortality rate is 3.39%. Mortality rate is not Casemix Adjusted. National PROMs: Groin Hernia National PROMS: Renacres Hospital: REQUIREMENT is for ADJ. Health Gain. EQ-5D Hip Replacement National PROMS: Renacres Hospital: REQUIREMENT is for ADJ. Health Gain. Oxford Hip. Primary Hip. Knee Replacement National PROMS: Renacres Hospital: REQUIREMENT is for ADJ. Health Gain. Oxford Knee Score *volumes are too low to be reported. Page 24 of 35

25 Readmissions National Readmissions: Renacres Hospital: Our figures are incomplete compared to SUS readmissions reports. This is because we have not been logging these on RiskMan. Therefore NHS figures used to maintain comparability. VTE assessment National: Renacres Hospital: C Difficile rate National: Renacres Hospital: SUI s Severity level 1 National: Renacres Hospital: Page 25 of 35

26 Friends and Family Test National: Renacres Hospital: Responsiveness to Personal Needs National: Renacres Hospital: Page 26 of 35

27 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 Infection prevention and control Renacres 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. Page 27 of 35

28 As can be seen in the above graph our infection control rate has decreased over the last year due to change in case mix. All Staff undergo Infection Control Training at Induction and annually as part of the Mandatory Training Programme, which includes both practical training and e- learning Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Renacres 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. Renacres Hospital PLACE audit took place in April 2014 and the following is an overview of the scores achieved: Cleanliness 98.09% Food 92.9% Privacy 86% Condition 96.12% Page 28 of 35

29 3.2.3 Safety in the workplace Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. 3.3 Clinical effectiveness Renacres 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 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. Page 29 of 35

30 3.4 Patient experience All feedback from patients regarding their experiences with Ramsay Health Care are welcomed and inform service development in various ways dependent on the type of experience (both positive and negative) and action required to address them. All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour letters and cards are displayed for staff to see in staff rooms and notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. All negative feedback or suggestions for improvement are also 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 Page 30 of 35

31 Satisfaction Scores Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/ s Patient focus groups PROMs surveys Care pathways patient are encouraged to read and participate in their plan of care Patient Satisfaction Surveys Satisfaction Scores NHS/Private Patients / /15 Renacres Hospital Our patient satisfaction surveys are managed by a third party company called Qa Research. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient s views. Every patient is asked their consent to receive an electronic survey or phone call following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services. Any text comments made by patients on their survey are sent as hot alerts to the Hospital Manager within 48hrs of receiving them so that a response can be made to the patient as soon as possible. 3.5 Patient Feedback (Received via Friends & Family April 2014 first 30 reported comments, listed in consecutive order) Very pleasant experience Extremely likely Well looked after, friendly and caring Staff were friendly and caring. Facilities were very good. Only bad thing was a relative couldn't stay with me Page 31 of 35

32 Clean, efficient, pleasant staff Everything was clean and hygienic. The staff were very kind and extremely helpful explaining everything at each stage and listening to any concerns. I felt myself to be in safe hands throughout Everything was excellent 10/10 Excellent Excellent care and attention Excellent care, before during and after Extremely likely I was treated like a VIP guest! I was well looked after. They went through all sorts of checks to make sure all information was correct Pleasant cheerful staff Professional treatment Staff friendly and pleasant. Everything went smoothly. Staff explained everything clearly. Thank you good care from everyone The help and efficiency of all staff who dealt with me plus the excellent communication and explanation of the procedure and aftercare Very friendly, very efficient, thank you Very good service Very prompt and pleasant attention by all staff. Hospital clean and well equipped. Everyone so nice and really care for you, lovely hospital and lovely staff The staff have been very kind and informative Well looked after, couldn't fault the service or care Clean, friendly and very efficient. Would be very happy to come back again Clean room, friendly staff, quickly attended to and nice touch with complimentary gift Everyone was so nice All round first class treatment for a necessary procedure. All the staff are fantastic. Could not have been made to feel more welcome. The place runs like a clock Cannot fault it in any way. Great place, great staff. Clean efficient and friendly. Page 32 of 35

33 Appendix 1 Services covered by this quality account Treatment of Disease, Disorder Or injury Services Provided Audiology, Cardiology, Cosmetics, Cosmetic Dentistry, Dermatology, Ear, Nose and Throat (ENT), General Medicine, General surgery, Gynaecological, Nephrology, Neurology, Neurosurgery, Ophthalmic, Orthopaedic, Pain Management, Podiatry, Psychiatry, Psychology, Physiotherapy, Rheumatology, Speech Therapy, Sports medicine, Urology, Vascular. Peoples Needs Met for: All adults 18 yrs and over All children 3 yrs and over, outpatients only Surgical Procedures Cosmetics, Day and Inpatient Surgery, Dermatology, Ear, Nose and Throat (ENT), General surgery, Gynaecological, Neuro surgery, Ophthalmic, Oral maxillofacial surgery, Orthopaedic, Urology, Vascular All adults 18 yrs and over excluding: Patients with blood disorders (haemophilia, sickle cell, thalassaemia) Patients on renal dialysis Patients with history of malignant hyperpyrexia Planned surgery patients with positive MRSA screen are deferred until negative Patients who are likely to need ventilatory support post operatively Patients who are above a stable ASA 3. Any patient who will require planned admission to ITU post surgery Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g. from kitchen to bathroom or dyspnoea at rest) Poorly controlled asthma (needing oral steroids or has had frequent hospital admissions within last 3 months) MI in last 6 months Angina classification 3/4 (limitations on normal activity e.g. 1 flight of stairs or angina at rest) CVA in last 6 months Diagnostic and screening Family Planning Services Audiology, GI physiology, Imaging services, Nerve conduction studies, Mobile MRI and CT, Phlebotomy, Urodynamics, Urinary Screening and Specimen collection. Gynaecology patient pathway, insertion and removal of inter uterine devices for medical as well as contraception purposes However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment. All adults 18 yrs and over All children 3 yrs and over, outpatients only All adults 18 years and over as clinically indicated Page 33 of 35

34 Appendix 2 Clinical Audit Programme 2014/15. Each arrow links to the audit to be completed in each month. Page 34 of 35

35 Renacres Hospital Ramsay Health Care UK We would welcome any comments on the format, content or purpose of this Quality Account. If you would like to comment or make any suggestions for the content of future reports, please telephone or write to the General Manager using the contact details below. For further information please contact: Telephone: Web: Page 35 of 35