QUALITY ACCOUNTS 2015/2016

Transcription

1 QUALITY ACCOUNTS 2015/2016 NO REPORTED MRSA BACTERAEMIA IN THE PAST 5 YEARS Page 1 of 32

2 Contents Introduction Page Welcome to Ramsay Health Care UK and The Westbourne Centre 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 2015/16 (looking back) Clinical Priorities for 2016/17 (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 2015/16 Quality Accounts PART 3 REVIEW OF QUALITY PERFORMANCE 3.1 The Core Quality Account indicators 3.2 Patient Safety 3.3 Clinical Effectiveness 3.4 Patient Experience Appendix 1 Services Covered by this Quality Account Appendix 2 Clinical Audits Page 2 of 32

3 Welcome to Ramsay Health Care UK The Westbourne Centre 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 32

4 Introduction to our Quality Account This Quality Account is The Westbourne Centre s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on. Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this didn t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share. Page 4 of 32

5 Part Statement on quality from the General Manager Sarah Rush General Manager, The Westbourne Centre As the General Manager of The Westbourne Centre I am passionate about ensuring that we deliver consistently high standards of care to all of our patients. Our Vision; As a committed team of professional individuals we aim to maintain high standards of services with patient care remaining our focus for everything we do. The Westbourne Centre has been established for 7 years. We offer a range of services to private and NHS patients, ensuring that patient care is at the centre of what we do. This is delivered through a commitment to teamwork and professionalism between all parties. Our Quality Accounts details the actions that we have taken over the past year in order to ensure that our high standards in delivering patient care are maintained and for those areas where we have identified where we can improve, we have implemented changes to our processes in order to be able to deliver the required improvements to the delivery of our patient care. Our Quality Account has been produced to provide information about how we monitor and evaluate the quality of the services that we deliver throughout The Westbourne Centre. We hope to be able to share with the reader our progressive achievements that have taken place over the past year. The Westbourne Centre has a very strong track record as a safe and responsible provider of Day Case services and we are proud to share our results. At The Westbourne Centre we believe that each member of staff plays a part in the success of the unit. We have a training and education plan which involves all members of our administrative and clinical teams. Our Quality Accounts have been developed with the involvement of our staff who have very much involved with developing a systems approach to risk management which focuses on making every effort to reduce the likelihood and consequence of an adverse event or outcome associated with treatment of a patient. To ensure a coordinated approach to the delivery of care for patients and to monitor the adherence to professional standards and legislative requirements the Clinical Effectiveness Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and Page 5 of 32

6 safety performance of The Westbourne Centre. These committees have reviewed and commented on the details within these Quality Accounts. The quality accounts give all parties and providers access to quality activities and patient treatment outcomes at The Westbourne Centre. If you would like to comment or provide me with feedback then please feel free to contact me on the following number or via ; or Sarah Rush Page 6 of 32

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. Sarah Rush General Manager The Westbourne Centre Ramsay Health Care UK This report has been reviewed and approved by: Mr Hiroshi Nishikawa - MAC Chair and Clinical Effectiveness Committee Chair Mr James Beech Regional Director Ramsay Health Care UK Coordinating NHS Commissioners Dudley CCG The management team at The Westbourne Centre work in partnership with the MAC and the CEC ensuring high quality patient care is at the centre of what we do. Regular meetings with the above committees ensure best practice and sharing of results. Page 7 of 32

8 Welcome to The Westbourne Centre The Westbourne Centre is a day case hospital in the heart of the Edgbaston Medical Quarter in Birmingham. We provide fast, convenient, effective and high quality treatment for patients whether self-funding, medically insured or from the NHS. We accept private and NHS patients from the age of 18 and dental patients from the age of 3. All of our theatre cases are performed under local anaesthetic with or without sedation, which enables patients to be discharged on the same day. (We do not have the facilities for general anaesthesia so any patients requiring general anaesthetic are treated at our sister hospital, the West Midlands Hospital, in Halesowen). Our specialities include: Cosmetic surgery Restorative dentistry Oral and maxillofacial surgery Endodontics and orthodontics Ophthalmic surgery Orthopaedic surgery ENT ( Ear, Nose and Throat) General and vascular surgery Dermatology Non-surgical and beauty treatments The Westbourne Centre is centrally located with free on-site parking and is easily accessible via public transport. We also have disabled access to The Centre. Currently we employ a total of 21 contracted staff and this includes a mix of qualified nurses, HCAs, theatre practitioners, administration staff and receptionists. We are supported by a well qualified and experienced regular bank team. All Consultants undergo rigorous vetting procedures, ensuring only those who are qualified and experienced are granted practicing privileges. 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 For the period March 2015 to April 2016 the total number of patients treated was 1708, of which 1110 (65%) were NHS and 558 (35%) were private. We offer direct referral services for self pay and insured patients. All patients requiring NHS services are referred via their General Practitioner, or other primary care providers (such as Optometrists and Dentists) directly to the hospital, either by Extended choice network or paper referral. We work closely with our commissioning CCG at Dudley to provide a range of surgical services under the NHS Standard Contract via the Extended choice network Page 8 of 32

9 We hold educational sessions with local GP practices and other primary care referrers, with the help of our consultant body and clinical staff, and provide workshops for practice staff to support and assist them with the referral processes. Additional services The Westbourne Centre has access to Cavendish Imaging, an independent company based at the Centre. Cavendish Imaging provides a specialist imaging service (x-ray and CT scans) for the dental, oral and maxillofacial, facial, plastic and ENT surgeons as well as orthodontists. We also have a physiotherapist who provides treatment for post operative NHS patients and selffunding patients. Involvement in the community The Westbourne Centre is proud to support local charities and this year our nominated charity was muscular Dystrophy. Page 9 of 32

10 Part Quality priorities for 2016/2017 Plan for 2016/17 On an annual cycle, The Westbourne Centre 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 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 who experience our services. To achieve these aims, we have various initiatives underway which remain on going as we are consistent in our approach. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital. Page 10 of 32

11 Priorities for improvement A review of clinical priorities 2015/16 (looking back) Cleanliness Infection prevention and control audits continued as planned and local action plans developed as necessary to ensure the standards are met. The PLACE( Patient led Assessment of the Care Environment) audit was carried out for the first time in This year the audit has been repeated and the results published on the NHS choices website. Investment in day surgery facilities This project is on-going at The Westbourne Centre and we have continued to improve the pathway for Day case patients as part of the national project to offer the most efficient and effective patient journey. Falls - Any slips, trips and falls for all staff and visitors were reported through the central risk management reporting network. The Westbourne Centre is monitored centrally and reviewed following any incidents. In addition to this any patient falls are reported to the Health and Safety management group where they are collated and reviewed before being reported to the Clinical Effectiveness Committee. 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: From the list of core never events, there are 3 that could affect The Westbourne Centre: Wrong site surgery Retained instrument post-operation Intravenous administration of mis-selected concentrated potassium chloride The Westbourne Centre have put preventative measures in place and there have not been any Never Events reported in 2015/16 Acute Care Competencies / Vulnerable Adult training All staff at The Westbourne Centre have access and training in the protection of Vulnerable Adults. Ensuring safe competent staff are available to care for patients continued to be a high priority through 2015/16. Duty of Candour has been implemented throughout the Centre, since the introduction of the regulation in March 2015, through policy sharing and open forum discussion,to encourage a culture of openness. All incidents that are registered on Riskman are discussed at clinical effectiveness meetings and Clinical heads of department meetings. Any failure to implement this regulation would be clearly highlighted at one of these meetings and appropriate action taken. Page 11 of 32

12 CQC ratings have not been awarded to date as we await our inspection notification. In preparation for the inspection, we have undergone a self- assessment and are making the following improvements. Safe -The CEC structure has been strengthened and minutes made more robust. Actions to close the loop on incidents, complaints and meeting minutes to be improved and therefore helping to provide greater evidence of much of the good work taking place and the lessons learned from incidents and complaints. Effective- More evidence of formal action planning and closing the loop is required on audits and action plans. Work has started with this with more robust action plans being produced, and the out comes from audits are feeding into action plans This is in progress but needs further work. Caring- very good feedback from patients on the care provided, both through survey results and face to face interviews. Staff are very supportive of patients and clearly motivated to care for them, with dignity and respect maintained well. We have few complaints and these were managed with sympathy and empathy Responsive- Whilst there are some good examples of listening to patients and developing actions to respond to feedback, these need to formalised more. Greater evidence of lessons learnt and the recording of actions is being developed. Well led- Senior management team are well respected by staff and are felt to be visible and supportive. A clinical strategy and business strategy have been developed, although further refinement of these is needed Clinical Priorities for 2016/17 (looking forward) Patient safety/ experience / clinical effectiveness RISKMAN In 2016/17 the incident reporting system will be continued to allow greater accuracy in recording incidents and will also support enhanced data and trend analysis. This will support our patient safety ethos. Ramsay Health Care UK are constantly looking at ways that risk and reporting incidents can be managed in an easier and more effective way. RISKMAN is a software reporting tool already in use in Ramsay Australia that is designed to allow all staff to log incidents directly into the system as they occur. This allows real time reporting and better ownership of incidents as it also allows those individual staff members to view the progress and outcome of any incidents reported. RISKMAN is our reporting tool for compliments and complaints and for any clinical incidents that we report both internally, centrally and nationally, for example the numbers of re-operations we perform, the numbers of readmissions of patients, deaths, infections and transfers of patients to other hospitals. Prior to RISKMAN all of these reports were generated and reported via different reporting tools. Page 12 of 32

13 Our aim to have all corporate risks transferred from our existing hard drive store to RISKMAN has been achieved. Going forward, we aim to transfer all local risks onto RISKMAN. Infection Control The Westbourne Centre is proud of its minimal infection rates and high percentage infection control audit results. Audits are undertaken in many areas of infection control including hand hygiene and surgical site. Our aim for 2016/2017 is the continuation of our high standards by close monitoring of our patient outcomes and maintaining our excellent infection control measures. We routinely achieve 100% results in most of the audits and aim to maintain this high standard in the coming year. Reducing the risk of developing thrombosis VTE (formation of thrombosis following surgery) is still very high on the agenda because of the risks to health and outcomes following surgery. For that reason we continue to strive to improve reporting data and compliance to all patients at risk and to those undergoing sedation. Through careful pre assessment and risk assessment we can reassure our patients that their wellbeing is our priority. Patients are also empowered to reduce those risks by information given to them at pre assessment and by preventive treatment e.g. early mobilisation and the use of specific compression anti-embolism stockings. PROMS We monitor the national PROMs results for Hernia and varicose vein surgery by offering all patients who undergo this type of surgery the opportunity to complete a questionnaire before and after surgery to monitor an improvement in their quality of life. Encouraging their use identifies poor outcomes and allows us to review practice where necessary. Benchmarking through national PROMS website. Link: PLACE April 2013 saw the introduction of PLACE, which is the new system for assessing the quality of the patient environment, replacing the old Patient Environment Action Team (PEAT) inspections. The assessments apply to hospitals, hospices and day treatment centres providing NHS funded care. We carried out this audit and published for the first time, in 2015.It has been repeated in April 2016 with excellent feedback from the patients conducting the audit. Page 13 of 32

14 PLACE will see our patients be a part of the team in assessing how the environment supports patient s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on the care environment and does not cover clinical care provision or how well staff are carrying out their job. These assessments take place every year and results reported publicly to help drive improvements in the care environment. The results show how all hospitals are performing nationally and locally. Patient Satisfaction Surveys Qa Research- Surveys carried out by our external research company show that our patients are extremely satisfied when asked please give your overall opinion of the care you received during your stay, regularly achieving a 100% score. Although we score high in areas relating to staffing, cleanliness and treating our patients with dignity and respect, we still have areas where we can show improvement and we aim to do this in the coming year. Friends & Family After the successful role out of in-patient and day case friends and family our next priority is the improvement in participation of the friends and family survey in the out-patient department. Please see page 29 for further details around results and graphs Page 14 of 32

15 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 2015/16 The Westbourne Centre provided and subcontracted 10 NHS services. The Westbourne Centre has reviewed all the data available to them on the quality of care in all 10 NHS services provided. The income generated by the NHS services reviewed in 1 April 2015 to 31 st March 16 represents 100% per cent of the total income generated from the provision of NHS services by The Westbourne Centre for 1 April 2015 to 31 st March 16. Ramsay uses a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year. The scorecard is reviewed each quarter by the hospitals senior managers together with Regional and Corporate Senior Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement. In the period for 2015/16, the indicators on the scorecard which affect patient safety and quality were: Human Resources Staff cost % Net Revenue % Agency cost as % of Total staff cost - 3 % % Staff Turnover - 23% % Sickness % (3 long term) (11% without long term) Appraisal % - 90% Mandatory Training % - 90% Number of Significant Staff Injuries - 0 Patient Formal Complaints per 1000 admissions -5 Patient Satisfaction Score -97.5% Number of Significant Clinical Events per 1000 admissions 10 Readmission per 1000 Admissions - 4 Quality Workplace Health & Safety Score - 92% Infection Control Audit Score % Consultant Satisfaction Score - 78% Page 15 of 32

16 2.2.2 Participation in clinical audit The national clinical audits and national confidential enquiries that The Westbourne Centre was eligible to participate in during 1 April 2015 to 31 st March 2016 are as follows: Elective procedures Elective surgery (National PROMs Programme) The national clinical audits and national confidential enquiries that The Westbourne Centre participated in, and for which data collection was completed during 1 April 2014 to 31 st 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. National Clinical Audits Name of Audit Participation % cases submitted Elective surgery (National PROMs Programme) Yes 96% Although 96% of the eligible cases admitted participated in the initial part of the survey, there were less than the minimum number of required post operative surveys to reach the threshold required to gain an average score. Consequently we are unable to comment on any health gain score as this figure is not published nationally. The report of the national clinical audit from 1 April 2015 to 31 st March 2016 was reviewed by the Clinical Governance Committee and The Westbourne Centre intends to take the following action to improve the quality of healthcare provided: The target for 2016 / 2017 will be for 100% cases to be submitted Local Audits There is a robust local Clinical Audit programme in place. Throughout the year 64 audits were undertaken. These included infection prevention and control, dental decontamination, theatre and dental radiology. The audit results are reviewed both nationally and at a local level by the Clinical Governance Committee. The clinical audit schedule can be found in Appendix 2. The Westbourne Centre intends to take the following actions to improve the quality of healthcare provided. Page 16 of 32

17 -Consent This audit is carried out quarterly and our average score was 94% Our aim for 2016/2017 is to achieve 100% This target will be achieved by ensuring stage one is signed at the initial consultation. -Care of the deteriorating patient This audit is carried out Bi annually and our average score was 75% Our aim for 2016/2017 is to achieve 90% Following some updated training we are now in the process of following procedure for post operative care regarding the care plan pathway and have started to score assess the patients. Up until now and the explanation for the low score, all observations were recorded on the post operative chart. They are now being recorded on the specific Early Warning Score document form and this will reflect in the score for the next audit Participation in Research There were no patients recruited during 2015/16 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 The Westbourne Centre s income from 1 April 2015 to 31st March 2016 was conditional on achieving Quality Improvement and Innovation goals agreed between them and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. CQUIN for 2015/2016 Dementia - Find, Assess, Investigate and Refer (FAIR) The Westbourne Centre have been successful in achieving 100% in the CQUIN for this period Statements from the Care Quality Commission (CQC) The Westbourne Centre is required to register with the Care Quality Commission and its current registration status on 31 st May 2016, is registered without conditions. The Westbourne Centre has not participated in any special reviews or investigations by the CQC during the reporting period. Page 17 of 32

18 2.2.6 Data Quality The Westbourne Centre submits both national and quality data at required reporting periods. Examples include: Mixed sex breaches Duty of candour Preventing people dying prematurely ( recording of smoking status) Ensuring people have a positive experience of care ( patient questionnaires) We consistently achieve 100% in most of our quality measures and aim to continue this for 2016/2017 NHS Number and General Medical Practice Code Validity The Westbourne Centre submitted records during 2015/16 to the Secondary Users Service(SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included: The patient s valid NHS number was: 99.96% for admitted patient care; 99.96% for out patient care; and 0% for accident and emergency care (not undertaken at our hospital). The General Medical Practice Code was: 100% for admitted patient care; 100% for out patient care; and 0% for accident and emergency care (not undertaken at our hospital). Page 18 of 32

19 Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall score for 2015/2016 was 85% and was graded green (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: Clinical coding error rate The Westbourne Centre conducted a clinical coding audit for dental patients during 2015/16 Westbourne Centre achieved the following levels in this audit as summarised in Table 1: Table 01: % Coding Accuracy Accuracy % Levels of Attainment Area Primary diagnosis 83% Secondary 44% This has been diagnosis addressed with training internally. Primary procedure 90% Secondary 90% procedure Recommendations R1 Arrangement of regular clinician engagement to improve clinicians understanding of clinical coding data requirements as well as the coders gaining a more sound understanding of the surgical procedures undertaken within the oral surgery specialty. R2 Development of a local policy and procedures document around the coding of oral surgery diagnoses and procedures. R3 Provide further training to coder(s) around the allocation of co-morbidities and those comorbidities that are always required to be coded Stakeholders views on 2015/16 Quality Account Dudley CCG as Lead Coordinating Commissioners have had the opportunity to review this document and at time of publishing have not requested any feedback to be added. Page 19 of 32

20 Part 3: Review of quality performance 2015/2016 Statements of quality delivery Fiona Brown Clinical Lead Review of quality performance 1st April st March 2016 Introduction 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 20 of 32

21 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 21 of 32

22 3.1 The Core Quality Account indicators Mortality: Period Best Worst Average Period Westbourne Oct 13-Sep 14 RKE RPA 1.20 Eng /14 NVC44 0 Oct 14-Sep 15 RJ RVW 1.18 Eng /15 NVC44 0 The Westbourne Centre considers that this data is as described for the following reason: There were no expected deaths as we do not have patients requiring palliative or long term care. PROMS: Period Best Worst Average Period Westbourne Hernia Apr14 - Mar15 RD R1H Eng Apr14 - Mar15 NVC44 * Apr15 - Sep15 RJL RR Eng Apr15 - Sep15 NVC44 The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre did not have sufficient numbers of patients taking part in this audit to be included in the %s The Westbourne Centre has taken the following action to improve this number and so the quality of its services:- By an increase in the relevant services available through additional clinic and theatre availability. PROMS: Period Best Worst Average Period Westbourne Veins Apr14 - Mar15 R1K 5.59 RTE Eng Apr14 - Mar15 NVC44 Apr15 - Sep15 RK RM Eng Apr15 - Sep15 NVC44 The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre did not have sufficient numbers of patients taking part in this audit to be included in the %s The Westbourne Centre has taken the following action to improve this number and so the quality of its services:- By an increase in the relevant services available through additional clinic and theatre availability PROMS: Period Best Worst Average Period Westbourne Hips Apr14 - Mar15 NTE RQX Eng Apr14 - Mar15 NVC44 Apr15 - Sep15 NVC RJL Eng Apr15 - Sep 15 NVC44 The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre do not undertake this type of procedure. PROMS: Period Best Worst Average Period Westbourne Knees Apr14 - Mar15 NT RE Eng Apr13 - Mar14 NVC44 Page 22 of 32

23 Apr15 - Sep15 RVV RK Eng Apr15 - Sep15 NVC44 The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre do not undertake this type of procedure. Readmissions: Period Best Worst Average Period Westbourne 2010/11 Multiple 0.0 5P Eng /11 NVC /12 Multiple 0.0 5NL Eng /12 NVC44 0 The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre has had no NHS readmissions. It is a day case hospital and the type of procedures carried out, would rarely warrant a readmission. Responsiveness: Period Best Worst Average Period Westbourn e to personal 2012/13 RPC 88.2 RJ Eng /14 NVC needs 2013/14 RPY 87.0 RJ Eng /15 NVC The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre is a day case hospital and so this indicator will not apply VTE Assessment: Period Best Worst Average Period Westbourne 15/16 Q2 Several 100% RWA 75.0% Eng 95.9% 15/16 Q2 NVC % 15/16 Q3 Several 100% RWW 61.5% Eng 95.6% 15/16 Q3 NVC % The Westbourne Centre considers that this data is as described for the following reasons: The Westbourne Centre carry out an assessment on all admissions and record the data appropriately. This indicator is also monitored internally, through the monthly audit programme. C. Diff rate: Period Best Worst Average Period Westbourn e per 100, /14 Several 0 RMP 32.5 Eng /13 NVC bed days 2014/15 Several 0 RPY 62.2 Eng /14 NVC The Westbourne Centre considers that this data is as described for the following reason: The Westbourne Centre has no cases to report. It is a day case hospital and patients are unlikely to contact C.Diff during such a short hospital stay. SUIs: Period Best Worst Average Period Westbourne (Severity 1 only) Apr 14 - Sep 14 Several 0 RP Eng 0.15 Apr 14 - Sep 14 NVC Oct 14 - Mar 15 RD RJC 1.53 Eng 0.18 Oct 14 - Mar 15 NVC The Westbourne Centre considers that this data is as described for the following reason:- Page 23 of 32

24 -There have been no serious incidents at The Westbourne Centre recorded on Riskman. This open system of reporting incidents is closely monitored and reported on by the Ramsay Corporate team at Head Office and results shared and nationally. F&F Test: Period Best Worst Average Period Westbourne Jan-15 Several 100% RCUEF 72.7% Eng 95.7% Jan-16 NVC44 NA Feb-16 Several 100% RCUEF 74.2% Eng 95.7% Feb-16 NVC % The Westbourne Centre considers that this data is as described for the following reason:- -The Westbourne Centre take part in the F&F test but the numbers are not included in the national average as we are a day case hospital only. 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 The Westbourne Centre has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 7 years. We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to minimise potential incidents year on year. Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year. A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice. Programmes and activities within our hospital include: Link personnel from The West Midlands Hospital support our own lead IC nurse at The Westbourne Centre and we have links with our local NHS Trust Microbiologist and local NHS Trust Infection Control Nurses. Page 24 of 32

25 Infection Rates (percentage of Admissiosns) E-Learning and Mandatory training sessions held for all clinical staff. Actively involving the infection control nurse in working in the clinical environments to audit and advise staff members and consultants in infection control issues including hand hygiene. Our lead Infection control nurse advises staff on reporting mechanisms for infections /wound problems using examples of reporting tools and policies available. Infection Rates / / /16 The Westbourne Centre The Westbourne Centre is proud of the low figure of less that 0.2% of all admissions and will aim to continue with such vigilance in monitoring and auditing infection control, in the forthcoming year Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually within the Ramsay group and The Westbourne Centre will take part again this year.it provides 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. We are pleased to be able to display our results from this year s audit The overall site score was 91% Page 25 of 32

26 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. All staff are actively encouraged to report incidents as by doing this we can identify areas for improvement. All incidents are then reviewed by the Health and Safety Team, root cause analysis is carried out and any trend and or recommendation is acted upon. They are also reported into the central reporting tool, RISKMAN, to ensure trends and key issues are highlighted group wide and lessons shared/actions taken across the company where necessary in a timely and structured fashion. All incidents that are reported on are divided into subsections separating clinical from nonclinical, with clinical incidents coming under the umbrella of clinical effectiveness. Page 26 of 32

27 Retrnn to Theatre (Percentage of Admissiosns) Annual risk assessment audits maintain up to date and effective safe practice within the Centre 3.3 Clinical effectiveness The Westbourne Centre has a Clinical Governance team 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 The Westbourne centre 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 and consistent with our track record of successful clinical outcomes. The Westbourne Centre has a 0.8% return to theatre rate for 2015/2016. Return to Theatre Score / / /16 The Westbourne Centre 3.4 Patient experience All feedback from patients regarding their experiences with The Westbourne Centre 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. Page 27 of 32

28 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 fed back 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 fed back via the various methods below, and are regular agenda items on Local Governance Committees and at Head of department meetings for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and Dept of Health bodies occurs as required and according to Ramsay and DH policy. Feedback regarding the patient s experience is encouraged in various ways via: Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48hrs of a patient making a comment on their web survey Yearly CQC patient surveys Friends and family questions asked on patient discharge We value your opinion leaflet Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback. Written feedback via letters/ s Patient focus groups PROMs surveys Care pathways patient are encouraged to read and participate in their plan of care Patient Satisfaction Surveys put in graphs 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. Page 28 of 32

29 Satisfaction Scores Satisfaction Scores NHS/Private Patients / /16 The Westbourne Centre As can be seen in the above graph our patients are 90.5 % satisfied. This relates to the questions asked please give your overall opinion of the quality of your care and How likely are you to refer your friends and family to the hospital. The slight decline in results from the previous year reflect the significant increase in business. We will endeavour to aim for 95% in the forthcoming year. Although we score high in areas relating to staffing, cleanliness and treating our patients with dignity and respect, we still have areas where we can improve and these include giving patients enough information about their medication prior to discharge including any potential side effects. Page 29 of 32

30 Appendix 1 Services covered by this quality account Treatment of Disease, Disorder or Injury Lasers for - Hair Reduction - Vascular/Pigmented Lesions - Laser Eye Surgery Shockwave Therapy Ambulatory and day surgery Surgical Procedures All surgical Treatments under LA/ Sedation - Dental implants - Minor oral/periodontal surgery - Cosmetic - Dermatological - General Surgery - Ophthalmic - Minor Orthopaedic Diagnostic - Phlebotomy - Specimen collection - Histology - Nerve conduction study Page 30 of 32

31 Appendix 2 Clinical Audit Programme. Each arrow links to the audit to be completed in each month Audit Programme v /16 Hospital Name: The Westbourne Centre Implemented: July 2015 Authors: R. Saunders / A. Shannon / N. Carre / A. Blake For review: June 2016 Use arrow symbol to locate required audit JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Medical Records NHS Dent Surg NHH Dent Surg NHS Dent Surg NHS Dent Surg Traffic light score VTE / Det Pt VTE PtDet VTE N & H VTE Det Pt VTE N & H Consent Pre admission / Discharge Column1Green 100% Care Pathways and Variance Tracking Cool Amber 90-99% Controlled Drugs Amber 80-89% Prescribing Hot Amber 70-79% Medicines Management Red 69% and under Dental Enviro Decontam Med Devices Enviro Deconta m Theatre Infection Prevention and Control* Organisat ional Surgical Safety Hand hygiene Isolation Anaesthet ic PVCCB Peri op Surgical Safety UCCB 100% Med Devices Enviro DecontamMed Devices Enviro Decontam Med Devices Clin Effect Organisat ional Surgical Safety Hand hygiene CVCCB SSI Anaesthe tic Peri op Surgical Safety Clin Effect Hand hygiene PVCCB UCCB Infection Prevention and Control - Environmental Audit Environ Environ Environ Environ Transfusion Compliance Allogenic Traceability Autologous Traceability *Key: CVCCB = Central Venous Catheter Care Bundle SSI = Surgical Site Infection PVCCB = Peripheral Venous Cannula Care Bundle UCCB = Urinary Catheter Care Bundle Det Pt = Deteriorating Patient N&H = Nutrition and Hydration VTE = Venous Thromboembolism Copyright 2014 Ramsay Health Care UK Page 31 of 32

32 THE WESTBOURNE CENTRE 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: Neurological Centres Quality Accounts 2013/14 Page 32 of 32