Quality Account 2011/12

Transcription

1 Quality Account 2011/12 Page 1 of 38

2 Contents Introduction Page Welcome to Ramsay Health Care UK and Oaks Hospital 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 2011/12 (looking back) Clinical Priorities for 2012/13 (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 Stakeholders views on 2011/12 Quality Accounts PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 Patient Safety 3.2 Clinical Effectiveness 3.3 Patient Experience 3.4 Case Study Appendix 1 Services Covered by this Quality Account Appendix 2 Clinical Audits Page 2 of 38

3 Welcome to Ramsay Health Care UK Oaks 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 22 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, PCTs and acute Trusts. Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high quality patient care is at the centre of what we do and how we operate all our facilities. This relies not only on excellent medical and clinical leadership in our hospitals but also upon our overall continuing commitment to drive year on year improvement in clinical outcomes. 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. 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. 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 38

4 Introduction to our Quality Account This Quality Account is the Oak s 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. The previous Quality Account for 2010/11 was developed by our Corporate Office. Each site within the Ramsay Group developed its own Quality Account for 2010/11 which included some Group wide initiatives, but also described the many excellent local achievements and quality plans that we would like to share. This Quality Account 2011/12 is in the same format as the previous years. Page 4 of 38

5 Part Statement on Quality from the General Manager Mr Ian Milne, General Manager, The Oaks Hospital, Colchester Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As the General Manager, I am passionate about ensuring that high quality patient care is our main focus and delivered to a high standard. This relies not only on excellent medical and clinical leadership but also on our overall continuing commitment to drive year on year improvement in clinical outcomes. The Oaks Hospital has a tradition of working closely with Consultants, external stakeholders such as the local primary care trust (PCT) and General Practitioner (G.P) surgeries as well as our patients to ensure the best quality healthcare is consistently being delivered. Our hospital staff are fully trained in the latest procedures and thus maintain all areas to the highest standards. Working within the Department of Health (DOH) guidelines we focus on patient safety and cleanliness to minimise infection. Any patient who wants to satisfy themselves on the quality of the hospital and its Consultants can be reassured by the Care Quality Commission s (CQC) latest report from the unannounced inspection that was carried out on the 19 th January 2012 which support the hospital s excellent reputation. As General Manager of the Oaks Hospital, I take great pride in the service we offer to our patients and relatives; this is only achieved through a cohesive team effort and approach. Our Quality Account is information for our patients and commissioners to assure them we are committed to sharing our progressive achievements from one year to the next. As a long standing and major provider for healthcare services across the world, Ramsay has a very strong record as a safe and responsible healthcare provider and we are proud to share our results. Our emphasis is to ensure patients receive safe and effective care, that they feel valued and respected in decisions about their care ensuring they are fully informed about their treatment at each step of their pathway. We especially value patient s feedback about their stay, treatment and clinical outcome. Patient safety is our highest priority and we provide sufficient qualified and trained staff to deliver the service in a safe environment. We ensure that our staff are competent through a robust recruitment process and training programmes. We believe it is essential to provide the right person in the right role at the right time to deliver safe and effective treatment and care. Page 5 of 38

6 Staff have competency based assessments in practice and are trained on all the equipment they are required to use and signed off as competent. The development of this Quality Account was determined by the Executive Management Team within Ramsay Health Care UK. All professional and management teams at local level have been represented in producing this account. Page 6 of 38

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. Mr Ian Milne General Manager The Oaks Hospital Ramsay Health Care UK Signature.. Date.12/06/2012 This report has been reviewed and approved by: Mr Donald Menzies, Consultant General and Laparoscopic Surgeon Medical Advisory Committee Chair Signature Date 12/06/2012 Mr Simon Dixon, Consultant Anaesthetist Clinical Governance Committee Chair Signature.Date 12/06/2012 Mr Richard Parsons, Regional Director Signature.. Date 12/06/2012 Page 7 of 38

8 Welcome to The Oaks Hospital The Oaks Hospital offers a comprehensive range of specialist surgical and medical procedures, along with the development of new services in line with patient needs. Consideration for our patients is at the heart of everything we do. We are constantly seeking new ways of working and bringing in fresh clinical practices that will improve outcomes for our patients. Our approach to service delivery, which currently includes working in partnership with the NHS, is courteous and professional and we take great pride in our ability to innovate and look at new ways of working. We have developed a competency based education programme for our clinical staff to ensure they maintain a wide, evidence based, skill framework. All Consultants undergo rigorous vetting procedures, ensuring only those who are qualified and experienced are granted practicing privileges which are reviewed on a regular basis. The hospital is strictly regulated and audited by the Care Quality Commission, the governing body responsible for maintaining standards in healthcare, and the latest report can be found at We are registered with the Care Quality Commission for 57 bedrooms, our inpatient facilities include three rooms which can accommodate paediatric patients and their relatives, as well as six high dependency rooms which enable closer monitoring of patients who may require it during their stay. Following our recent expansion programme at the Oaks Hospital which was completed in December 2011, we have expanded our theatres to include a fourth theatre for minor procedures and Endoscopy, three of our theatres have laminar flow. We also expanded in size our outpatient facilities which include a new ophthalmology suite as well as a new designated 11 bay Ambulatory Unit which was built to meet the growing need of day care facilities. We also have radiology and physiotherapy departments within the hospital. Specialties at the hospital include orthopaedic surgery, ophthalmology, endoscopy, urology, spinal surgery, pain management, dermatology, ENT, dental, general, vascular, gynaecology, podiatry, oncology, breast and laparoscopic surgery. Cosmetic surgery is also available for a wide range of procedures. Diagnostic services include X-ray, mammography, ultrasound and mobile CT and MRI. Other registered services that are available at the Oaks Hospital please see Appendix 1 Statement of Purpose. We provide fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of three years), whether medically insured, self-pay, or from the NHS. The Oaks Hospital is situated on the outskirts of Colchester. There is ample free parking which has also been expanded to accommodate our growing business and the hospital is easily accessible via train or bus. In 2011 we treated a total number of 54,488 patients % Private patients and 47.14% NHS patients. The nursing staff to patient ratio is 1: between 5 and 8 depending on patient dependency. There is an experienced Resident Medical Officer on site 24 hours a day. Page 8 of 38

9 Our Staffing establishment includes: Consultants 139 Non Consultants 22 Registered Nurses 44 Healthcare Assists 14 Support Staff 27 Admin Staff 48 Physiotherapists 9 Radiographers 5 Operating Department Practitioner s 3 Management Personnel 4 We work closely with our local NHS Trust, Colchester Hospital University Foundation Trust (CHUFT) where we have local agreements in place for provision of services which include Pharmacy, Blood Transfusion and Infection Control. We also have services provided by The Doctors Laboratory (TDL) based at our sister hospital, The Rivers at Sawbridgeworth for pathology. The Rivers also provide the Oaks Hospital with some of the chemotherapy drugs which are administered to our private patients. We work closely with our local PCT to provide a range of services under the standard acute contract via the choose and book system and via paper referral pathway. We offer direct referral services for private/self pay/insured patients. All patients requiring NHS services are referred via their GP directly to the hospital or via a clinical assessment service (CAS/CRS). Oaks Hospital s GP Liaison Officer continues to be committed to forging links and building and maintaining relationships with GP Surgeries in the local catchment area. The Oaks Hospital staff take part in numerous fundraising events to raise funds for local charities. This year the Hospital has chosen the Essex Air Ambulance and St.Helena Hospice as their chosen charities. We held a Quiz night at the Oaks with a guest speaker from Essex Air Ambulance. We also have a Book Swap for the staff to bring in their books to swap with others and make a donation to this charity. Outside activities have included sponsored cycle races such as the Tour de Tendring Bike Ride and Dedham Fun Run. We also actively get involved in supporting the local CHAPS men s health charity. Edna the Oaks Hospital s mascot kangaroo aka our Credit Controller and IT coordinator at Oaks Hospital ran in the annual Charity Mascot Race at Colchester United Football Club during half time of the Colchester vs. Sheffield United match. Our favorite kangaroo competed with other local mascots to complete one lap of the pitch in order to raise money for St Helena Hospice, a Colchester-based charity. Page 9 of 38

10 Part Quality priorities for 2011/2012 Plan for 2011/12 On an annual cycle, the Oaks Hospital develops an operational plan to set objectives for the year ahead which each department is then committed to working with their teams to achieve these. 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 ongoing 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. Priorities for improvement A review of clinical priorities 2011/12 (looking back) Patient safety 1. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. For further details see: The Oaks Hospital has a vigorous system of reporting clinical incidents and taking appropriate actions to ensure patient safety is paramount. During this reporting year there was one serious untoward incident that was classed as a never event. A thorough investigation was undertaken with robust action plans and monitoring to ensure that this does not reoccur. 2. VTE risk assessment. In September 2008, the Department of Health issued its guidance on Risk Assessment for Venous Thromboembolism (DH 2008). Page 10 of 38

11 The objective is to improve the quality of patient care by minimising the risk of VTE incidents. We had no reported incidences of Venous Thromboembolism at the Oaks Hospital. We continue to abide by policy and ensure all patients are risk assessed and have appropriate prophylaxis. 3. Infection Control The Oaks Hospital carried out regular infection control audits throughout this reported year. The results showed improved scores in all areas especially the environmental audit and patient environmental action team audit. We completed our actions outlined in the previous quality account. 4. Real time incident reporting A RIMS User Group has been established for Ramsay, which is looking at ways of improving reporting mechanisms. This will assist us locally in relevant data being inputted more efficiently and reporting tools more widely available in order to improve patient safety outcomes. This group continued until 2012 where changes to the reporting system is currently underway and is described in the section Pulse results This was superseded by The Sunday Times Best Companies To Work For survey. This is important as satisfied, well trained and competent staff will ensure patient safety risks are reduced. Ramsay as a whole has had some really good results these include very positive responses to questions about my team and my company. We are currently awaiting the full report of results and will then form a local working party with a task to create a 90 day action plan. 6. Acute Care Competencies ensuring safe, competent staff are available to care for patients. All of our clinical staff have completed the acute care competencies and training is underway for staff to address any learning outcomes. We have a departmental training record where all staff s training is recorded. Clinical effectiveness 1. Ambulatory Day Care better outcomes and improving patient experience Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both medical and surgical) to hospital for a planned procedure, returning home the same day i.e. the patient does not incur an overnight stay. The Oaks Hospital completed its expansion plans by December 2011 which included the purpose built 11 bay Ambulatory Unit which commenced its service January Since then, our staff have been treating day case patients successfully under this new streamlined service. 2. Group pre operative assessments for major joint replacements The Oaks aims to provide group sessions for patients prior to coming into hospital for joint replacements, giving information in an environment which encourages group Page 11 of 38

12 interaction and discussion as well as post operative group sessions for education and exercise classes. To date this service has not yet commenced due to staff vacancies which have now been successfully filled. We have decided to focus first on the group post-operative physiotherapy classes which have been implemented successfully. We plan to expand this service to our pre operative patients in the coming year.. 3. Improve National Benchmarking how do we compare? It was recognised that we needed more transparency between ourselves and other independent sector providers/the NHS in order to monitor and improve our services. This is even more important now we are working in partnership with the NHS. Many areas of benchmarking are now in place including VTE risk assessment monitoring, outcome study and customer satisfaction results. We are still waiting to see if the National Hellenic project will provide national benchmark figures for key performance indicators (such as activity/volumes, mortality, day case rates, unplanned readmissions, average length of stay, unplanned transfers, returns to theatre). The available benchmarks are now reported monthly to the local NHS commissioning PCT and regular meetings are held to discuss any improvements or action plans. 4. Improve ward efficiency by adopting the Productive Ward initiative more time to care The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for Innovation and Improvement (2008). It focuses on the way ward teams work together and organise themselves, in order to reduce the burden of unnecessary activities, and releasing more time to care for patients in a reliable and safe manner within existing resources. The approach is very much bottom up with all ward staff suggesting ideas and ways in which they could improve their environment and processes. The Ward Staff at The Oaks launched the project in May 2011 and have embraced the concept and leading in change processes to enable more time spent with patients. The Oaks Hospital completed its foundation modules and implemented changes to practice such as reorganisation of patient folders, clinical documentation, utility areas and store rooms. We have now moved onto the next chosen module focusing on Patient observations. 5. Improved patient information It was recognised from our patient satisfaction survey results that our patients were not always receiving written discharge information on discharge. This is important as even though we always tell our patients everything they need to know before going home, a written reminder ensures that they have the same information should they need to refer to it at a later date. We are pleased to report that in the last year our rate for this question in our patient satisfaction survey has increased from quarter % to 96.3% in quarter Page 12 of 38

13 6. CQUIN The commission for quality and innovation (CQUIN) payment framework enables commissioners to reward excellence by linking a proportion of provider s income to the achievement of local quality improvement goals. Each commissioner agrees a number of different CQUIN s at the beginning of the financial year with each of their providers. These include in year targets as well as final outcome targets. The Oaks Hospital income from 1st April 2011 to 31st March 2012 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework during this period. For 2010/11 The Oaks Hospital had four CQUIN: Goal Number Goal Description Overall target to achieve Final score achieved 1 VTE To reduce avoidable death, disability and chronic ill health from Venousthromboembolism 2 Patient Experience Improves responsiveness to personal needs of patients 90% or above of all adult inpatients must have a VTE assessment on admission to hospital using the clinical criteria of the national tool. The indicator is a composite, calculated from 5 survey questions. Each describes a different element of the overarching patient experience theme "responsiveness to personal needs of patients". The elements are: 1) Involvement in decisions about treatment/care, 2) Hospital staff being available to talk about worries/concerns, 3) Privacy when discussing condition/treatment, 4) Being informed about side effects of medication, 5) Being informed who to contact if worried about condition after leaving hospital. 100% 94.7% 3 Global Trigger Tool - Global Trigger Tool to measure overall harm Improving awareness of potential safety issues Provider to produce a report of lessons learnt and actions taken to prevent a reoccurrence. 100% 4 Smoking Cessation - Encouraging all patients and The Provider is required to ensure that Page 13 of 38

14 staff to quit smoking 1) A No smoking policy is in place for patients and staff, on the premises or in uniform (staff). 2) 98% of All NHS and Private Patients have their smoking status recorded. 3) 90% of NHS and Private Patients who are identified as smokers seen in outpatients/preadmission are sign posted to NHS Stop Smoking Support Services and offered a referral. Policy issued and approved 100% 100% Patient experience informing patient choice 1. Increasing the use of Patient Reported Outcomes Studies (PROMs) We continue to monitor the national PROMS results for Hip. Knee, Varicose Veins and Hernia surgery by offering all patients who undergo this type of surgery the opportunity to complete a questionnaire before and after surgery to monitor improvement in their quality of life. Encouraging their use identifies poor outcomes and allows us to review their practice where necessary. We share the results with the multi-disciplinary team within the Oaks and the local Clinical Governance Committee and encourage them to use the results to review their practice by meeting and discussing with their teams and benchmarking against other sites Clinical Priorities for 2012/13 (looking forward) Patient Safety 1. Risk Management (Riskman) This is the new software tool for reporting clinical and safety incidents, complaints and compliments that Ramsay have adopted. This will capture all the data required to meet the requirements placed on the business without paper format. Through a positive attitude to reporting incidents we can learn and improve the safety of our facilities and care provided for patients, staff and visitors. The Oaks Hospital has been nominated as part of the pilot before being rolled out to all other units. Clinical Effectiveness 2. Allocate Rostering System This project is being rolled out across the Ramsay group with plans underway to improve our rostering and man hours management. This will allow units to have a better allocation of staff, looking at skill mix which will enable patient centred focus and direct patient care. Following the pilot phase which commences May 2012 and will take approximately 6 weeks, the rostering tools will be implemented across the Eastern Region to include the Oaks Hospital. Page 14 of 38

15 3. Paediatrics Very few independent Hospitals offer a broad range of Paediatric services because they are unable to comply with the strict regulations and recruit the necessary specialist staff. Ramsay is launching Children s services and will be rolling out to units who undertake this service in due course. This service aims to encourage children as well as parents and carers to become involved in decisions about their care. We already provide Children s services to the highest possible standard and with investment this will enable us to continue to provide the best possible paediatric care within the community/local area. 2.2 Mandatory Statements Review of Services During 2011/12 the Oaks Hospital provided and/or subcontracted 35 NHS services. The Oaks hospital has reviewed all the data available to them on the quality of care in 100% of these NHS services. The income generated by the NHS services reviewed in 1st April 2011 to 31st March 2012 represents 100% per cent of the total income generated from the provision of NHS services by the Oaks hospital for 1st April 2011 to 31st March Ramsay continues to use a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard continue to be reviewed each year. The scorecard is reviewed each quarter by the hospitals senior managers together with regional and Corporate Managers. The balanced scorecard approach continues to be an extremely successful tool in helping the company benchmark against other hospitals and identifying key areas for improvement. In the period for 2011/12, the indicators on the scorecard which affect patient safety and quality were: Human Resources HCA Hours as % of Total Nursing 17.3% Agency Hours as % of Total Hours 0.8% % Staff Turnover 7.8 % % Sickness 0.5% Total Lost Worked Days Number of Significant Staff Injuries Participation in clinical audit The national clinical audits and national confidential enquiries that the Oaks hospital participated in, and for which data collection was completed during 1st April 2011 to 31st March 2012, 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. Page 15 of 38

16 National Clinical Audits for Quality Accounts (NA = not applicable to the services provided) For information/reports on audits participated in please go to the following link: Name of Audit Participation % cases submitted Peri-and Neo-natal N/A no service provided for under 3 years of age at the Oaks Hospital. Children N/A service we deliver to over 3 years of age are for elective surgical procedures with no patient comorbidities. Acute care Cardiac arrest (National Cardiac Arrest Audit) Long term conditions Elective procedures Yes Yes No-activity minimal 0% - no cardiac arrests at the Oaks Hospital during the audit period. Q2 83% Hip, knee and ankle replacements (National Joint Registry) Elective surgery (National PROMs Programme) Cardiovascular disease Renal disease Cancer Trauma Psychological conditions Blood transfusion Bedside transfusion (National Comparative Audit of Blood Transfusion) Health promotion End of life Yes Yes NA NA NA NA NA Not enough activity of patients requiring blood transfusion to qualify for audit. NA NA Q3 87% Q4 93% Q1 89% We will continue to consider participation in any national audits as required and appropriate to the Oaks Hospital s case mix and service criteria. Page 16 of 38

17 Local Audits The reports of 63 (which includes 12 infection prevention and control, 3 transfusion, 4 physiotherapy and 8 radiology. These audits run from 1st July 2011 to 31st June 2012 and are reviewed by the Corporate and local Clinical Governance Committees and the Oaks hospital intends to take actions appropriately to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. Key main audits that have been identified with robust action plans include: Care of the deteriorating patient Nutrition and Hydration Consent process Prescribing Medicines Management Some of these audits are relatively new for this year with new policies and clinical documentation that has been implemented Participation in Research There were no patients recruited during 2011/12 to participate in research approved by a research ethics committee Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework Details of the agreed goals for 2012/13 and for the following 12 month period once agreed with the commissioning PCT will be available electronically at and are outlined below: Goal Number Goal Name Description of Goal Goal weighting (% of CQUIN scheme available) 1 VTE % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool 2 Patient experience Improve NHS patient experiences The indicator is a composite, calculated from 5 survey questions. Each describes a different element of the overarching patient experience theme Quality Domain (Safety, Effectiveness, Patient Experience or Innovation) 20% Safety, Effectiveness and Patient Experience 20% Patient Experience Page 17 of 38

18 3 NHS Safety Thermomet er "responsiveness to personal needs of patients". The elements are: 1) Involvement in decisions about treatment/care, 2) Hospital staff being available to talk about worries/concerns, 3) Privacy when discussing condition/treatment, 4) Being informed about side effects of medication, 5) Being informed who to contact if worried about condition after leaving hospital. Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter, and VTE This CQUIN incentivises the collection of data on patient harm using the NHS Safety Thermometer harm measurement instrument (developed as part of the QIPP Safe Care national work stream) to survey all relevant patients in all relevant NHS providers in England on a monthly basis Detailed information on the appropriate patients and relevant settings for use of the NHS Safety Thermometer are defined in the NHS Safety Thermometer guidance for use1. The intention is for all NHSfunded providers, across community, mental health, acute and residential and nursing care, including NHS-funded independent sector providers, to use the 20% Safety Page 18 of 38

19 4 Avoidable Pressure ulcer reduction and elimination 5 Supporting patients with high BMI 6 Improving Medicines Manageme nt Safety Thermometer, apart from where exceptions apply, as detailed in the guidance. This will allow nationally consistent data to be collected and published as well as facilitating local improvement activity. The Elimination of avoidable grade 2, 3 and 4 pressure ulcers by December This CQUIN will require monthly measurement of all grade 2, 3 and 4 pressure ulcers, which will by December 2012 indicate the elimination of all avoidable grade 2, 3 and 4 pressure ulcers. This performance will be required to be sustained through quarter /12. Support patients to lose weight 1. Inpatients have their weight recorded and BMI calculated 2. Patients with a BMI of over 30 are given information on the risks of obesity and contact details of the Local NHS Weight Management Service 3. If Patient accepts a Referral can be made to Patient/GP in discharge letter and patient information leaflet To reduce missed doses in Antibiotic therapy, Warfarin, insulin and Parkinsons Drugs This CQUIN incentivises the collection of data on patient harm related to missed Antibiotic, Warfarin, Insulin, oral Methotrexate and Parkinsons drug doses to enable delivery of a 10% Safety and Patient Experience 10% Innovation 20% Safety, Effectiveness and Patient Experience Page 19 of 38

20 reduction in the number of missed doses. Current quarterly audits review missed doses at the end of patient s course of treatment this CQUIN seeks to change the audit process to undertake a sample audit once a quarter of all patients on antibiotics, Warfarin, Insulin, oral Methotrexate and Parkinsons drugs to identify missed doses within the previous 24 hours. This change in audit process will enable real time issues and actions to be identified and facilitate a reduction in missed antibiotic Warfarin, Insulin, oral Methotrexate and Parkinsons drugs doses going forward but will also enable early feedback to clinical staff at patient level to enable specific changes in patient needs and reduce harm events at individual patient level. Once baseline information has been obtained (End of Q1) it is intended to agree a percentage improvement by quarter 4 on the number of missed antibiotic, Warfarin, Insulin, oral Methotrexate and Parkinsons drugs doses. Totals: % Page 20 of 38

21 2.2.5 Statements from the Care Quality Commission (CQC) The Oaks Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions. The Oaks Hospital had an unannounced inspection from the CQC on the 19th January The visit was a positive experience with two improvements actions and one compliance action to address. The full report can be found on the CQC website. The Care Quality Commission has not taken enforcement action against the Oaks hospital during 2011/12. The Oaks Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. Page 21 of 38

22 2.2.6 Data Quality The Oaks Hospital will be taking the following actions to improve data quality. The unit s data quality super user is continuing to monitor the 18 week and data quality patient pathway issues weekly and is reviewing processes internally and throughout the administration functions. NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2010/11 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: 99.66% for admitted patient care; 99.30% for outpatient care; and 0% for accident and emergency care (not undertaken at Ramsay hospitals). The General Medical Practice Code: 99.96% for admitted patient care; 99.82% for outpatient care; and 0% for accident and emergency care (not undertaken at Ramsay hospitals). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall score for 2011/12 was 77% and was graded green (satisfactory). Clinical coding error rate The Oaks Hospital was not subject to the Payment by Results clinical coding audit during 2011/12 by the Audit Commission. Page 22 of 38

23 2.2.7 Stakeholders views on 2011/12 Quality Account A copy of our Quality Account was sent to our relevant Local Involvement Network (LINk) and the leading commissioning primary care trust (PCT) North East Essex for comments prior to publication. These comments are as follows: 31 May 2012 Mr Ian Milne General Manager The Oaks Hospital 120 Mile End Road, Colchester, Essex CO4 5XR Dear Ian North Essex PCT response to The Oaks Hospital (Ramsay Group) Quality Account for 2011 to 2012 This is the final year that Quality Accounts are being commented on by the Primary Care Trusts in north Essex. The Oak Hospital (Ramsay Group) is demonstrating, in your account that you work hard to deliver quality care. You tell us that you are passionate about ensuring the delivery of high quality patient care and your account reflects this aspiration. We are pleased that your account indicates both the ways in which you have succeeded in delivering the aims you set out in last year's account and where you need to undertake further work to continue to improve. The PCT encourages the continued use of Releasing Time to Care and of your efforts to improve cleanliness. Your introduction gives a high level view of the services delivered at The Oaks Hospital, its unique aspects and some of the issues that you have been addressing internally which give readers of the report an overview of service provision and your ethos. You give a description of your participation in clinical audit and your achievement of a green outcome for the Information Governance Tool Kit assessment, in a year when the expectations to achieve such an outcome have risen. Your Quality Targets for are: Introduce RISKMAN software Allocation Rostering System Launch Children's Services We support your choice of quality priorities, although limited in number they are far reaching in their ability to improve and innovate. The conclusion of the north Essex PCT cluster is that The Oaks quality accounts for 2011 to 2012 provide an accurate and balanced picture of key performance indicators for the reporting period. Yours sincerely Denise Hagel Interim Director of Nursing NHS North Essex Page 23 of 38

24 Part 3: Review of quality performance 2011/2012 Statements of quality delivery Matron, Juliet Driver Review of quality performance 1st April st March 2012 Introduction Our 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. (Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK) Ramsay Clinical Governance Framework 2012 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 Page 24 of 38

25 Coherence Ramsay Health Care Clinical Governance Framework NICE / NPSA 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 National Patient Safety Agency (NPSA). 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, working closely with the commission PCT as part of the Standard Acute Contract. 3.1 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. Page 25 of 38

26 Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs that follow Infection prevention and control The Oaks hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 4 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. At the Oaks our Infection Control Nurse is also the Eastern Regional lead for Ramsay Healthcare. The Oaks Hospital are also involved with the local North Essex Cluster IPC committee. Programmes and activities within our hospital include: The Oaks has an in house infection control team led by an infection control nurse involving staff members from every department and a Consultant Microbiologist from the local trust. The infection control team meet quarterly to review all aspects of infection control including audits, training, infection control issues. Infection control is mandatory for all staff and is part of the Ramsay e learning programme. In addition to the mandatory training the infection control nurse carries out hand hygiene training and audits as per the infection control audit programme as seen in appendix 2 and for assurance with the local PCT as part of the Standard Acute Contract. The results of all audits are discussed at the local infection control meetings, the Clinical Governance Committee, Heads of Department meetings and Clinical HoDs Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient Environment Assessment Team (PEAT) audits. These assessments include rating of privacy and dignity, food and food service, access issues such as signage, bathroom / toilet environments and overall cleanliness. Page 26 of 38

27 % Every catering establishment within East Essex have to undertake an annual inspection from the Food Standards Agency to ensure compliance and standards are met. We achieved the highest score of 5 stars, which is an excellent achievement for our catering department. The Oaks has an in house housekeeping team who take great pride in the cleanliness of the hospital and carry out self audits to ensure standards are being met. There is also an annual infection control audit of all departments that audits the standards of cleanliness in relation to infection control. The catering department is also on site which allows patient s access to a wide range of appetising and nutritious meals appropriate to their needs. All staff are aware of the absolute requirement to treat all patients with dignity and respect and this is monitored via our external and internal patient questionnaires. PEAT Audit % Year We have received our 2012 score from the information centre for health and social care. The Environmental score = 4 Good, the Food score = 5 Excellent and the Privacy and Dignity score = 5 Excellent. We have strived to improve our score by maintaining high standards of cleanliness, catering facilities and the general environment of the hospital. Much improved score over the last 4 years has been steadily improving each year, mainly due to the implementation of cleaning schedules and staff s commitment 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 Page 27 of 38

28 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. The Oaks Hospital has a local Health & Safety committee that meets bi-monthly to discuss all matters relating to health and safety and to review any adverse events that have occurred. There is a comprehensive system in place to test all equipment (facilities and medical). A slips, trips and falls action plan and corporate policy with a new falls risk assessment has also been developed to reduce the number of patients falls. Untow ard Incidents /10 10/11 11/12 As can be seen in the above graph our adverse events rates have decreased over the last year. There have been no trends identified. This is also due to improved reporting of all incidents for all departments within the hospital by empowering the staff to report and be honest and open culture. 3.2 Clinical effectiveness The Oaks Hospital has a Clinical Governance 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 28 of 38

29 Unexpected Returns To Theatre /10 10/11 11/12 As can be seen in the above graph our returns to theatre has decreased over the last year and remains low compared to the Ramsay average highlighted by red line Readmission to hospital Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness. As with return to theatre, any emerging trend with specific surgical operation or surgical team in common may identify contributory factors to be addressed. Ramsay rates of readmission remain very low and this, in part, is due to sound clinical practice ensuring patients are not discharged home too early after treatment and are independently mobile and not in severe pain. Unplanned Readmissions /10 10/11 11/12 As can be seen from the above graph our readmissions rate is higher than last year, there has been no significant trends identified. 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 and a bi-monthly Page 29 of 38

30 report of all feedback is sent to all departments for staff to read. 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 standard agenda items on Local Committtees for discussion, trend analysis and further action where necesary. Escalation and further reporting to Ramsay Corporate and DOH bodies occurs as required and according to Ramsay and DOH policy. Feedback regarding the patient s experience is encouraged in various ways via: Patient satisfaction surveys We value your opinion leaflet available from the hospitals Verbal feedback to Ramsay staff - including Consultants, the management team which includes Matron, General Manager and Heads of departments 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 Our patient satisfaction surveys are managed by an independent company called The Leadership Factor (TLF). They print and supply a set number of questionnaire packs to our hospital each quarter which contain a self addressed envelop addressed directly to TLF, a letter of explanation from the Director of Safety and Clinical Performance for each patient to complete the questionnaire and send back. Results are produced quarterly (the data is shown as an overall figure but also separately for NHS and private patients). The results are available for patients to view on our website. Patient satisfaction scores for overall quality show the majority of patients feel they receive excellent quality of care and service in the Oaks hospital. To record a satisfaction index over 90%, a very high proportion of our patients have scored 9 or 10 out of 10 for their satisfaction with all the requirements. This is underlined by comparing our hospitals Satisfaction Index against those achieved by other organisations across all sectors of the UK economy where the full range of customer satisfaction is 50% to 95% with the median just below 80%. Page 30 of 38