Boston West Hospital. Quality Account 2014/15

Boston West Hospital Quality Account 2014/15

Contents Introduction Page 3 Welcome to Ramsay Health Care UK 3 Introduction to our Quality Account 4 PART 1 STATEMENT ON QUALITY 5 1.1 Statement from the General Manager 5 1.2 Hospital accountability statement 7 PART 2 12 2.1 Priorities for Improvement 12 2.1.1 Review of clinical priorities 2014/15 (looking back) 12 2.1.2 Clinical Priorities for 2015/16 (looking forward) 14 2.2 Mandatory statements regarding quality of NHS services 15 2.2.1 Review of Services 15 2.2.2 Participation in Clinical Audit 17 2.2.3 Participation in Research 18 2.2.4 Goals agreed with Commissioners 18 2.2.5 Statement from the Care Quality Commission 20 2.2.6 Statement on Data Quality 20 2.2.7 Stakeholders views on 2014/15 Quality Accounts 22 PART 3 REVIEW OF QUALITY PERFORMANCE 25 3.1 The Core Quality Account indicators 27 3.2 Patient Safety 30 3.3 Clinical Effectiveness 33 3.4 Patient Experience 34 3.5 Case Studies 37 Appendix 1 Services Covered by this Quality Account 39 Appendix 2 Clinical Audits 40 Appendix 3 Glossary 41

Welcome to Ramsay Health Care UK Boston West Hospital is part of the Ramsay Health Care Group The Ramsay Health Care Group, was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals. We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver thousands of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs and Clinical Commissioning Groups. Introduction Statement from Mark Page, Chief Executive Officer, Ramsay Health Care UK 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 our 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. Page 3 of 42

Introduction to our Quality Account This Quality Account is Boston West Hospitals 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 42

Part 1 1.1 Statement on Quality from the General Manager Carl Cottam, General Manager Boston West Hospital As the General Manager of the Boston West Hospital I am passionate about ensuring that we deliver consistently high standards of care to all our patients. Our Vision is that As a committed team of professional individuals we aim to consistently deliver quality holistic care for all our patients across a full range of care services. We believe we are able to achieve this by continually updating our key skills and knowledge enabling us to deliver evidence based clinical practice throughout the Hospital. Our Quality Account details the actions that we have taken over the past year to ensure that our high standards in delivering patient care remain our focus for everything we do. Through our vigorous audit regime and by listening to our stakeholders, including patient feedback, we have been able to identify areas of good practice and where we can improve the care patients receive. This has enabled us to refine some of our processes to make improvements to the service we offer our patients. We have enhanced our training and education plan throughout the year involving both the administrative and clinical teams. It is important we have robust training programs to deliver excellent care and service standards. Our Quality Account provides information about how we monitor and evaluate the quality of the service that we deliver. We hope to share our progressive improvements over the past year. The Boston West Hospital has a very strong track record as a safe and responsible provider of health care services and we are proud to share our results. Our Quality Account has been developed with the involvement of our staff who have been instrumental in developing a systems approach to risk management, which focuses on providing safe quality care to mitigate the risk of adverse events. Page 5 of 42

To ensure we have a coordinated approach to the delivery of the care we provide we have our Clinical Governance Committee and Medical Advisory Committee who monitor the adherence to professional standards and legislative requirements. The committee s review the hospitals clinical performance and activity on a quarterly basis. The committees have reviewed and agree with the content and actions details within the quality account. As General Manager, I am aware of all aspects of clinical quality and NHS services provided at Boston West Hospital and can confirm the accuracy of this document. If you would like to comment or provide feedback regarding the content of the Quality Account, please do not hesitate to contact me at carl.cottam@ramsayhealth.co.uk or telephone 01733 842308. Page 6 of 42

1.2 Hospital Accountability Statement To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate. Carl Cottam General Manager Boston West Hospital, Ramsay Health Care UK This report has been reviewed and approved by: BWH Medical Advisory Committee Chair Mr Nazeer Dahar, Consultant Urologist BWH Clinical Governance Committee Chair Dr Marian Necas, Consultant Anaesthetist BWH Medical Director Mr Viktor Csok, Consultant General Surgeon Regional Director - Mr James Beech The report has also been shared with the following groups for their review and comment prior to submission. Lincolnshire Clinical Commissioning Group Health Watch Lincolnshire and Lincolnshire Health Scrutiny Committee Boston West Hospital Patient Participation Group Page 7 of 42

Welcome to Boston West Hospital Boston West Hospital is part of the Ramsay Health Care Group The Boston West Hospital has been part of the local community for 10 years. We have a dedicated workforce that is committed to making each and every patient feel secure and safe. Whether our patients are coming in for a consultation or day surgery we want them to feel that they are cared for by compassionate and highly trained staff that provide skilled care to our patients. Boston West Hospital is a purpose built facility which provides services for assessment, diagnosis and treatment of common medical conditions, and has a suite of outpatient and treatment rooms which have recently been refurbished to create an additional spacious consultation room. A wellequipped modern theatre undertakes a range of surgical procedures and endoscopic (diagnostic) investigations. Support services include a three stage Sterile Services Unit, which meets the stringent standards set by the Department of Health. The Hospital provides a wide range of services covering NHS and private day case facilities for the following specialties: Orthopaedic Ophthalmology General Surgery Pain Management Gynaecology Gastroenterology Urology Page 8 of 42

Physiotherapy Cosmetic Surgery ENT Our full list of services can be found in Appendix 1. We provide safe, convenient, effective and high quality treatment for adult patients (excluding children below the age of 18 years), whether privately insured, self-pay, or from the NHS. A high percentage of our patients have come from the NHS sector, patients choosing to use our facility through Choose and Book. Our services help to ease the pressure on The Pilgrim NHS Hospital, Lincoln County Hospital and other local NHS facilities. We have worked closely with our NHS Clinical Commissioners, Lincolnshire South CCG, to ensure improved access for patients requiring day case surgery. Over the past 10 years our establishment has grown from strength to strength. From our friendly reception staff to our highly skilled surgeons, patient care and opinions are what matters most; and our positive feedback from our patients gives our entire team great pride. Not only do we continue to have positive feedback from our service users we have recently developed a suite of patient information leaflets to provide patients additional information and support regarding take home medications on discharge. From review of our patient feedback, since the implementation of the leaflets we have scored 100% in this area for patient satisfaction. We have over 16 highly trained nursing staff who, alongside a wide variety of other healthcare professionals, deliver the highest level of care. At the Boston West Hospital, we provide medical and surgical services for privately insured, selfpaying and NHS patients. We strive to offer the same level of outstanding care to all our patients. Last year we admitted a total of 2,980 patients, 95% of which were NHS. An additional 590 patients were seen per week in our outpatient department by one of our 35 Consultants. At Boston West Hospital we offer consultant led care, meaning that all our patients are seen by a Consultant at each step of their patient care pathway. We consistently engage with local general practitioners to update them regarding the services we offer and the most current pathways for patient care. This has resulted in our ability to tailor care to meet the needs of patients and improve quality. We have the support of a Quality Improvement Manager during the last financial year to invest and support our commitment to quality to provide our patients with the best clinical care and patient experience. We also continue to foster good relationships with other local healthcare providers. This affiliation promotes a robust governance process which in turn enhances patient safety. Page 9 of 42

We also work close with a nominated charity each year, this year we have supported LIVES and Marie Curie Cancer care. Over the past year Hospital staff have been working together with patients to raise funds for charity. Ramsay Health Care has donated resources and staff have volunteered time to arrange fundraising activities. Patient engagement and involvement continues to be a high priority as we strive to keep patients at the heart of everything we do. The Boston West Hospital Patient Group plays the valuable role of critical friend to the Hospital and supports in a number of ways including undertaking regular reviews of patient communication and conducting our annual Patient Led Assessment of the Care Environment (PLACE) audit. In addition to patient involvement our GP Liaison Officer works closely with GP Practices, Opticians and communities across the county to ensure that both referrers and patients are aware of our services and that these services meet the needs of local people. We provide a programme of free clinical education and training to support health professionals in their continued professional development (CPD). This is well received by GPs and Optometrists and also helps us strengthen relationships and improve communication between our Consultants and local clinicians. These educational sessions have been delivered by our Consultants and Clinical Leads at GP Practices throughout Lincolnshire and at Boston West Hospital. Boston West Hospital is approved by the General Optical Council as a provider of Continued Education and Training (CET) enabling us to deliver accredited training to Optometrists, dispensing Opticians and support staff. 2015 marks 10 years since Boston West Hospital first began providing healthcare to the people of Lincolnshire. Many of the team have been working at the Hospital since it opened including Matron, Sue Harvey and Medical Director, Viktor Csok. Ramsay Health Care recognises and rewards long service and is keen to retain and develop its work force investing widely in training and offering development opportunities. Boston West Page 10 of 42

Hospital has recently taken on several apprentices who will be learning new skills within both our clinical and administrative departments. Being an apprentice at Boston West Hospital has given me a fantastic opportunity to gain the hands-on experience I wanted. To be able to work with such a hard-working and friendly team has really helped me feel welcome, at ease and part of the team. It has given me a great step forward at the beginning of my career Beth Barai Apprentice HCA Patients tell us how important good customer service is to their experience of healthcare in our hospital. In response Ramsay Health Care have introduced a Customer Service Excellence programme (CSE) to encourage excellence in our staff and recognise members of the Boston West Hospital team who demonstrate excellent customer service. Staff who deliver exceptional care, attention and support can be nominated by patients, carers, visitors and colleagues and work their way to bronze, silver and the ultimate gold CSE award. To date members of our clinical, administration, housekeeping and sterile services departments have achieved bronze, silver and gold awards. Part 2 Samantha Bisby, Health care Assistant (HCA), of Boston West Hospital is the first member of staff within Ramsay Health Care UK to achieve her prestigious gold award having received over 36 nominations from patients and colleagues for demonstrating exceptional customer service. Page 11 of 42

2.1 Quality priorities for 2014/2015 Plan for 2014/15 On an annual cycle, Boston West Hospital develops an operational plan to set objectives for the year ahead. We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services. To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital. Priorities for Improvement 2.1.1 A review of clinical priorities 2014/15 (Looking Back) Patient Experience Patient Satisfaction During 2014/15 we pledged to continue to focus on fostering an environment that enables us to learn from patient feedback as we value our patients feedback in order to develop and grow the services we offer. We commissioned a scheme to promote quality and innovation in conjunction with our Clinical Commissioning groups to monitor and measure our patient feedback through audit and patient satisfaction surveys. The key objective during 2014/15 was to focus on patient pain management at the point of discharge. The indicator set out to improve communication about pain management for all admitted patients, ensuring that all in-patients have relevant and appropriate literature and advice on discharge including the provision of Managing Your Pain After Your Operation leaflet. During 2014/15 we conducted a number of patient surveys to gauge the success of the work we had Page 12 of 42

completed regarding communications. The patient satisfaction survey scores for the questions covering information on discharge regarding the management of pain showed an increase in patient satisfaction of 67%, with patient satisfaction scoring 100%. This work will be extended during 2015/16 to ensure the provision of the leaflets to patients along with full explanations given at both the Pre Admission Assessment and on discharge is embedded into our practice to maintain patient satisfaction in this area. Friends & Family Test The successful implementation of the friends and family test in our outpatient areas was also achieved. Clinical Effectiveness It is important for patients who chose to be treated by our clinicians that the procedures they undergo are effective and appropriate. We measure and record how effective we are by publishing data to inform and benchmark. Patient Recorded Outcome Measures (PROMs) Our clinical priority was to improve our response rate for groin hernia repair and varicose veins. The outcome measures enable healthcare professionals to measure the overall benefit of undertaking surgical procedures and the clinical effectiveness following that procedure. Patient Safety It is important for patients to know they are being cared for in a safe environment by staff who have the appropriate knowledge and skills. We also have a contractual requirement with our Clinical Commissioning Groups to achieve high standards of clinical safety. This is monitored through numerous audits, reports and inspections. Venous Thromboembolism (VTE) Our aim was to ensure that over 98% of patients have a completed VTE risk assessment and appropriate prophylaxis is provided. Throughout the year we have monitored our progress to review the standard of assessment. On review 100% of patients had a completed risk assessment during 2014/15. Early Warning Score (EWS) As part of ongoing work following the CQUIN from 2013/14 it was identified that a further suite of training materials was required and audits to be undertaken to monitor the effectiveness of the training following the release of new national guidelines. All staff were trained and further monitoring was carried out to analyse the effectiveness of the training. In 2014 Boston West Hospital implemented a further change to the EWS chart incorporating national guidance, with a Page 13 of 42

commitment to train staff in the use of new charts and monitor compliance with escalation of the deteriorating patient, Boston West Hospital achieved their target for this improvement with a compliance score of 97% 2.1.2 Clinical Priorities for 2015/16 (looking forward) Patient Experience Patient experience continues to be a key focus to ensure we deliver the highest level of patient care at Boston West Hospital. Fostering an environment that enables us to learn from patient feedback is critical to the growth and development of our services. Our aim in 2015/16 is to improve the process for patients who do not attend the hospital for their appointment concentrating on key services. The process aims to reduce waits and provide a more streamlined process for those services with high demand, which in turn will provide patients with a better experience, looking specifically into the area of endoscopy. As feedback is important to us, we plan to review the way in which HOT alerts and informal patient feedback is addressed to ensure all feedback is addressed and lessons learned where possible to improve the services we offer our patients. In 2015/16 we aim to develop a Consultant Newsletter to ensure the clinicians are aware of our activity in relation to governance and quality sharing lessons learned from the wider Ramsay group and highlighting key information from clinical audit and national guidelines to promote best practice. Clinical Effectiveness Sharing our findings from governance information and learning lessons is key, in order to progress the effectiveness of the hospital. During 2015/16 we will be introducing display boards within each department which will highlight key governance activity and performance. We will also be sharing lessons with key clinical staff regarding adverse events and sharing lessons from the wider Ramsay group for learning. Patient Safety 2014/15 has seen the theatre team build on their safety culture, with the sound implementation and ongoing review of the WHO checklist. Monthly clinical audits are completed to review clinical safety and effectiveness. The average compliance rate for these audits during 2014/15 was 98% and during 2015/16 we would like to build on these findings. We hope to continue this momentum and build on an already sound culture. During 2015/16 we have attached CQUIN activity (detailed on page 17) to theatres which we hope will provide ongoing improvements and enhance the good work which is already evident, when looking back on the previous year. Page 14 of 42

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. 2.2.1 Review of Services During 2014/15 the Boston West Hospital provided and/or subcontracted 9 NHS services. The Boston West Hospital has reviewed all the data available to them on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 1 April 2014 to 31 March 15 represents 95% of the total income generated from the provision of NHS services by the Boston West Hospital for 1 April 2014 to 31 March 15 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 to benchmark against other hospitals and identifying key areas for improvement. In the period for 2014/15, the indicators on the scorecard which affect patient safety and quality were: Human Resources In 2014/15 our expectation was to continue to recruit to permanent positions and retain permanent staff in order to continue to reduce the percentage of agency use. In 2013/14 our percentage use of agency was 4.92%, in 2014/15 the percentage of agency costs was 9%. Long term sickness, maternity leave, new starter induction and training contributed to lost hours. Staff hours worked per hospital day were 14.9 and staff costs as a percentage of net revenue were 20%. Levels of sickness saw a slight upturn in 2013/14. On review of the 2014/15 sickness saw a slight decrease by 0.5%. We continue to work with our Well Being Service to support employees both in the workplace and as part of a structured return to work service. The total skill mix calculation for the Boston West Hospital was completed by reviewing the contracted and bank hours for registered nursing staff and healthcare assistants. In the previous Page 15 of 42

financial year we planned to review the skill mix in the outpatient department based on a workforce review that had been undertaken. 9 Registered Nurses caring for patients 4 Health Care Assistants caring for patients 1 Health Care Apprentice The Boston West Hospital has a robust mandatory training program and regular monitoring of training compliance is completed. This allows us to meet contractual obligations as well as ensuring staff are compliant with requirement and can provide care competently. The Senior Management team are pleased to announce that the implementation of the employee engagement group has been positive and well received by the staff, proving a platform for staff to drive change in the Hospital. There were no (0) RIDDOR event(s) reported at the Boston West Hospital during this period. Patient Services The hospital reported 0.01% complaints per 1000 hospital patient days during 2014/15. The themes and trends of the complaints are reviewed by the Clinical Governance Committee and Medical Advisory Committee on a regular basis. Lessons learned from complaints are discussed in departmental meetings to offer staff an opportunity to reflect on the complaint and collectively discuss where improvements could be made. Ramsay also has an overarching view of governance and provides feedback and benchmarking information to the Boston West Hospital on a regular basis. The Boston West Hospital utilise an external organisation to gather unbiased data from patients about their experience and satisfaction with the services they have received. The data set is released on a quarterly basis in addition to the Friends and Family. The number of patients who required readmission following their discharge from hospital is reviewed on a monthly basis. In percentage terms the readmission rate relates to 0% of our day case stays during 2014/15. Feedback from our patients is important to us, based on the feedback during 2014, we have maintained or made improvements with an average compliance score of over 90% in the following areas Quality of Care Friendly welcome on arrival to hospital Cleanliness Page 16 of 42

Patients felt they were given enough privacy and dignity when being examined Information on discharge Ramsay also has two further patient feedback mechanisms the first being, We Value Your Opinion which allows patients to comment on their stay at discharge. The patient completes a questionnaire allowing free text for any comments or feedback. This feedback is reviewed by the Senior Management Team and areas identified for improvement are considered. The second mechanism is the Hot Alert this is a web based feedback questionnaire, allowing patients to comment on any aspect of their stay. All Hot Alerts are reviewed by the General Manager and Matron, the patient receives a written response based on their comment, to highlight any actions taken by the hospital to make improvements to the services we offer. Quality Our annual workplace health and safety score was 97%. The annual audit program is inclusive of reviewing infection prevention and control with periodic audits looking at a range of infection prevention and control activities including hand hygiene, isolation, surgical site surveillance, peripheral venous cannula care bundles, urinary catheter bundles and infection control environmental audits. The Boston West Hospital has a governance process which monitors significant clinical events. During the period 2014/15 our overall percentage for reported significant events was 0% per 1000 hospital days. 2.2.2 Participation in Clinical Audit During 1 April 2014 to 31 March 2015 Boston West Hospital participated in two (JAG & PROMS) national clinical audits and one national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that Boston West Hospital participated in, and for which data collection was completed during 1 April 2014 to 31 March 2015, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Name of audit / Clinical Outcome Review Programme Elective surgery (National PROMs Programme) No cases submitted 87 Page 17 of 42

The reports of one national clinical audits from 1 April 2014 to 31 March 11 2015 were reviewed by the Clinical Governance Committee and Boston West Hospital intends to take the following actions to improve the quality of healthcare provided. Continue to improve the process around PROMs compliance for Hernia patients Local Audits The reports of 70 local clinical audits from 1 April 2014 to 31 March 2015 were reviewed by the Clinical Governance Committee and Boston West Hospital. The Hospital intends to take the following actions to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. Feedback of audit results has been a focus of our work during 2014/15 ensuring findings and results are shared with the wider team for learning and improvement. During 2014/15 we have seen an improvement with our consent compliance. The Boston West Hospital have departmental meetings and feedback is given to staff regarding audit compliance, each audit that requires any improvement has an action plan attached. The clinical team have a topic of the week notice board where key topics from governance intelligence is shared and displayed, sharing the findings and lessons learned from audit. 2.2.3 Participation in Research There were no patients recruited during 2014/15 to participate in research approved by a research ethics committee. 2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Boston West Hospital s income from 1 April 2014 to 31 March 2015 was conditional on achieving quality improvement and innovation goals agreed by Boston West Hospital and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2014/15 and for the following 12 month period are available below. Page 18 of 42

Goal Name Indicator Name Indicator Description Friends & Family Test Early Implementation Implement the Friends & Family recommendations tests to the outpatient department Increase the questionnaire response rate for inpatient and daycase services NHS Safety Thermometer Dementia Pain Management Improve falls in hospital Find, assess and investigate Post-operative pain management Maintain falls performance throughout 14/15 All patients >75 years old undergo a face to face pre assessment, the proportion of patients identified as potentially having dementia are appropriately assessed and referred to a specialist if required. Nominate a named lead for dementia and provide training and education to staff. Ensure patients pain score is assessed in line with a nationally recognized pain assessment tool. Ensure pain assessments are recorded in line with policy and procedure 2015/16 CQUIN Activity Goal Name Indicator Name Indicator Description Surgical Safety Surgical site infection bundle Reduce harm to patients by - Removing hair around incision site Reduce surgical site infections by ensuring prophylactic antibiotics are given on time and discontinued on time, during and after the operative phase. To maintain normal body temperature by ensuring that a core temperature is recorded as per Ramsay policy Maintain normal serum glucose in known diabetics and avoiding surgery Ensure a team brief and debrief is completed prior to and after the theatre list Page 19 of 42

Safety Culture assessment for surgical team 2.2.5 Statements from the Care Quality Commission (CQC) Boston West Hospital is required to register with the Care Quality Commission and its current registration status on 31 March 2015 is registered without conditions. Boston West Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. 2.2.6 Data Quality The annual audit program reviews the quality of our data via clinical systems together with medical and paper records. In 2015/16 a key goal is to improve the process regarding the capture of patient data Produce a quality dashboard to review key KPI s and Governance issues via a traffic light system and report by exception Review and improve the PROMS data collection process to ensure all patients eligible to participate in the questionnaire are provided with a questionnaire. Continue to provide comprehensive reports regarding activity to the Medical Advisory Committee and Clinical Governance Committee which are supported by clinical audit. NHS Number and General Medical Practice Code Validity NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2014/15 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: The patient s valid NHS number: 99.97% for admitted patient care; 99.96% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). Page 20 of 42

Information Governance Toolkit Attainment Levels Ramsay Group Information Governance Assessment Report score overall for 2014/5 was 75% and was graded green (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: https://www.igt.hscic.gov.uk The Boston West Hospital successfully passed the ISO Information Governance Audit (27001) during 2014/15. Clinical Coding Error Rate Boston West Hospital was subject to the Payment by Results clinical coding audit during 2014/15, by the Audit Commission. The results are shown in the table below; no concerns were raised in relation to coding error rates during the audit. Hospital Site Audit Date Next Audit Date Primary Diagnosis Secondary Diagnosis Primary Procedure Secondary Procedure Boston NHS TC Jan 14 April 15 98.28% 91.96% 93.10% 97.78% Page 21 of 42

2.2.7 Stakeholders Views on 2014/15 Quality Account NHS South Lincolnshire CCG Commentary for Ramsay Boston West Hospital NHS South Lincolnshire CCG s main priority is to ensure that services are safe and of a high quality. The Boston West Quality Account highlights areas of service that demonstrate high quality care using the three key areas of effectiveness, safety and patient experience. As part of the national CQUIN for last year Boston West Hospital achieved the early implementation of the Friends and Family Test in the outpatient department and the hospital exceeded the 98% VTE risk assessment goal set for 2014/15 with 100% of patients being risk assessed. Further, to enhance patient safety during 2014/15, additional work was undertaken to update the Early Warning System to reflect national guidance and this was again supported with a comprehensive training package and compliance checks to ensure the clinical process was embedded. The focus on high quality clinical care and patient experience is welcomed by the CCG and the additional commitment to quality through the development of the shared Quality Improvement Manager during 2014/15 is supported. The CCG has conducted a review visit to the hospital during 2014 and there were a number of areas of good practice noted including demonstrable learning from incidents. South Lincolnshire CCG notes that the Boston West Hospital is required to register with the Care Quality Commission and its current registration status on 31 March 2015 has no restrictions. The Care Quality Commission has not undertaken any enforcement action against Boston West since its registration. South Lincolnshire CCG can verify that Ramsay Boston West Hospital has reported against all the mandated statements within the Quality Account where data is available. In terms of performance against the CQUIN scheme for 2014/15 Boston West Hospital fully achieved the following: Friends and Family Test NHS Safety Thermometer Dementia - Find, Assess, Investigate and Refer Pain Management Early Warning Score Compliance The CCG endorses the areas identified for improvement for 2015/16 and the associated initiatives as detailed within the Ramsay Boston West Account in particular the development of a consultant newsletter to support the sharing of best practice and lessons learned. The CCG notes the CQUIN scheme this year will continue to maintain emphasis on patient safety through the implementation of National Patient Safety Agency five steps to safer surgery. Page 22 of 42

The South Lincolnshire CCG CQUIN scheme for 2015/16 will consist of the following: Implementation of Surgical Site Infection Bundle o To reduce harm to patients by removing hair around incision site using correct intervention o To reduce surgical site infection by ensuring that prophylactic antibiotics are given on time and discontinued on time. o To maintain normal body temperature by ensuring that a core temperature is recorded as per Ramsay policy o Maintain normal serum glucose in known diabetics and avoiding surgery Surgical Team Communication and Safety Culture Assessment South Lincolnshire CCG endorses the accuracy of the information presented within the Ramsay Boston West Quality Account and the overall quality programme performance will be reviewed through the formal contract quality review process and triangulation through patient experience surveys. Statement on Boston West Hospital Ramsay Health Care Quality Report for 2014/15 This statement has been made behalf of Healthwatch Lincolnshire. We are pleased to have been asked by Boston West Hospital to contribute to the Quality Account; however given that this is our first account with Ramsay Health Care we feel it only pertinent to comment in the broadest way, due to time constraints we have not had opportunity to discuss more fully, a review of last year s priorities or the forthcoming years areas of focus and development. We found the report well produced and is easy to understand, this is critical when communicating and engaging with the general public, however we would ask that wherever possible Ramsay Health Care does not use abbreviations wherever possible. (NVC27 means nothing to the lay reader and only confuses) Priorities for 2015-16 Healthwatch Lincolnshire support the 3 priorities for 2015/16. However we would liked to have seen a greater explanation of how Ramsay Health involved partners and members of the public in developing these priorities, however we have no reason to believe there are any gaps within the priorities for this forthcoming year. Page 23 of 42

Priorities for 2014-15 We acknowledge the work and progress made with priorities for 2014/15 and would hope to be assured that although targets were achieved, they will continue to be regularly reviewed to maintain the standards achieved in 2014/15 Finally it is noted that independent patient experience feedback from Healthwatch Lincolnshire given to Ramsay has always been received in a positive and proactive manner and where appropriate patient views have influenced change. We welcome and support Ramsay in proactively seeking feedback from patients both internally and externally. Healthwatch Lincolnshire look forward to continuing engagement with the Ramsay Health Care, and its continued improvement in the services provided to patients. (This was a joint statement on behalf of Healthwatch and Health Scrutiny Committee for Lincolnshire) Boston West Hospital Patient Participation Group (PPG) Comments on Quality Account 2014 15 I thought it was a very comprehensive report with excellent information for whoever needs to know that amount of detail on the hospital (PPG Representative) Page 24 of 42

Part 3: Review of Quality Performance 2013/2014 Statements of Quality Delivery Matron, Sue Harvey Review of Quality Performance 1 April 2014-31 March 2015 Introduction This publication marks the sixth successive year since the first edition of Ramsay Quality Accounts. Through each year, month on month, we analyse our performance on many levels, we reflect on the valuable feedback we receive from our patients about the outcomes of their treatment and also reflect on professional opinion received from our doctors, our clinical staff, regulators and commissioners. We listen where concerns or suggestions have been raised and, in this account, we have set out our track record as well as our plan for more improvements in the coming year. This is a discipline we vigorously support, always driving this cycle of continuous improvement in our hospitals and addressing public concern about standards in healthcare, be these about our commitments to providing compassionate patient care, assurance about patient privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open and honest where outcomes and experience fail to meet patient expectation so we take action, learn, improve and implement the change and deliver great care and optimum experience for our patients. (Vivienne Heckford, Director of Clinical Services, Ramsay Health Care UK) 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. Page 25 of 42

Several models have been devised to include all the elements of Clinical Governance to provide a framework for ensuring that it is embedded, implemented and can be monitored in an organisation. In developing this framework for Ramsay Health Care UK we have gone back to the original Scally and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of all the necessary strategies, policies, systems and processes for effective Clinical Governance. The domains of this model are: Infrastructure Culture Quality methods Poor performance Risk avoidance Coherence Ramsay Health Care Clinical Governance Framework National Guidance Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Clinical Excellence (NICE) and Safety Alerts as issued by the NHS Commissioning Board Special Health Authority. Page 26 of 42

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. The Boston West Hospital review all National Guidance released from the National Institute of Clinical Excellence at the Medical Advisory Committee, all guidance releases from Ramsay are also issues to the Consultant Body to ensure they are aware of recent releases and requirements. 3.1 The Core Quality Account indicators All acute hospitals are required to report against the indicators below as part of the Quality Account. Boston West Hospital have only included indicators relevant to the services provided by the hospital. Data sets are routinely submitted to NHS and Non-NHS bodies via the Health and Social Care Information Centre, a comparison of the numbers, percentages, values, scores or rates of the NHS Trust and non-nhs bodies (as applicable) are included for each of those listed in the tables below. NVC27 is the code used for Boston West Hospital on the data information websites. Mortality The table below shows the Mortality data, the latest data release from the Health & Social Care Information Centre (HSCIC) the mortality data is a Summary Hospital-level Mortality Indicator (SHMI). The figures below have been extracted from the most recent data sets available. The data submission is to prevent people from dying prematurely and enhancing quality of life for people with long-term conditions as part of the NHS outcomes framework. Period Best Worst Average Period Boston West Jan13-Dec13 RKE 0.62 RXL 1.18 Eng 1 2013/14 NVC27 0 Apr13-Mar14 RKE 0.54 RBT 1.20 Eng 1 2014/15 NVC27 0 The Boston West Hospital considers the data is a true reflection of activity. Patient Reported Outcome Measures (PROMS) The information in the table below shows reviews data in relation to helping people to recover from episodes of ill health or following injury. The domain reviews patients feedback and the measure is the adjusted health gain described by the patient. The HSCIC data for PROMS includes private providers, with the most recent data release covering the period April 2013 March 2014. Hernia Period Best Worst Average Period Boston West Apr13 - Mar14 NT415 0.139 NVC11 0.008 Eng 0.085 Apr13 - Mar14 NVC27 0.135 Apr14 - Sep14 RXR 0.125 Several 0.009 Eng 0.081 Apr14 - Sep14 NVC27 * Page 27 of 42

The Boston West Hospital continually review the PROMS process at hospital level to increase patient participation and ensure the process is capturing the patient data at pre assessment. Further work is required to engage and communicate with patients regarding the NHS outcome measure. Varicose Veins Period Best Worst Average Period Boston West Apr13 - Mar14 RTH 11.292 NT350-16.849 Eng -8.698 Apr13 - Mar14 NVC27 * Apr14 - Sep14 RYJ -4.567 RWA -16.762 Eng -9.479 Apr14 - Sep14 NVC27 * There has been insufficient returns to pull benchmarking data from the PROMS submission, due to the low activity in this area. Further work is required to engage and communicate with patients regarding the NHS outcome measure. Readmissions The table below shows the data set reviewing patients aged 16 or over, who were readmitted to hospital within 28 days of being discharged. The latest data sets available from SUS have been reported on for this quality account. Period Best Worst Average Period Boston West 2010/11 Multiple 0.0 5P5 22.76 Eng 11.43 2010/11 NVC27 0 2011/12 Multiple 0.0 5NL 41.65 Eng 11.45 2011/12 NVC27 0 The Boston West Hospital considers the data is as described for the following reasons: Readmissions are below the national average and could be attributed to good standards of clinical care and treatment preventing readmission. Patients could also choose to represent at another provider Patients are provided with key information at the point of discharge about care services following their procedure. The Boston West Hospital will continue to provide patients with support with aftercare advice and encourage patients to return where clinically indicated. Responsiveness This data set looks at the positive experiences of care provided by Boston West Hospital. The data has been extracted from the Care Quality Commissions inpatient survey. The latest data release form the CQC has been reported, no data set was made available for independent sectors for this reporting period. The Boston West Hospital reviewed their feedback mechanisms in 2014/15 ensuring all feedback which comes via the hospital patient feedback forms is acted upon and the patient is provided with Page 28 of 42

a written acknowledgement of the issues raised. We will continue to listen and act upon feedback to improve responsiveness score despite exceeding the national average, as patient feedback is vital in enabling the hospital to make improvements to the services offered to patients. VTE Assessment The VTE assessment domain reviews data to see if patients are being treating and cared for in a safe environment and are being protected from avoidable harm. The data looks at all patients who have had an adequate risk assessment prior to admission in relation to the prevention of postoperative VTE events. Period Best Worst Average Period Boston West 14/15 Q2 Several 100% RNL 86.4% Eng 96.2% 14/15 Q2 NVC27 98.8% 14/15 Q3 Several 100% NT322 85.1% Eng 96.0% 14/15 Q3 NVC27 99.7% The data shows the Boston West Hospital as exceeding national benchmarking data, with consistent performance. The VTE management of patients post operatively has been reviewed via periodic audits during 2014/15, to ensure the best possible care is being delivered to patients, during 2013/14 postoperative assessments were introduced. Any changes to the treatment plan are noted and documented, treatment is then provided in accordance with the post-operative assessment, to mitigate patients from any avoidable harm. C-Difficile Rates The table below highlights the C-Difficile rates for the reporting period 2013/14 with a comparison available for the previous year. Period Best Worst Average Period Boston West 2012/13 Several 0 RVW 30.8 Eng 17.4 2012/13 NVC27 0.0 2013/14 Several 0 RMP 32.5 Eng 14.7 2013/14 NVC27 0.0 From the data Boston West Hospital are amongst the best performing organisations in the country for C-Difficile rates The Hospital considers the data described as the scores show consistent practice in pre assessment procedures. The antibiotic local policy to access antibiotic use in patients who access our services from a residential setting was implemented in 2014/15, the results show the policy has been well supported throughout 2014/15, maintaining a 0% rate in C-Difficile cases. The scores reflect good practice from clinical staff in the ability to isolate patients which required, promoting good infection control processes. The Boston West Hospital intends to continue its current practice to remain one of the best performing hospitals for their C-Difficile rates. Page 29 of 42

Friends & Family Test The NHS domain for the Friends and Family tests aims to seek the opinion of service users; ensuring patients have a positive experience of care. Period Best Worst Average Period Boston West Jan-15 Several 100% RPA02 51.2% Eng 94.0% Jan-15 NVC27 100.0% Feb-15 Several 100% RHU10 75% Eng 94.7% Feb-15 NVC27 99.3% The Boston West Hospital considers the data to be as described. The hospital places great emphasis on patient satisfaction and the friends and family test encompasses this. There has been consistent outstanding performance in patient satisfaction during the period of data analysis. This is supported by the overall scores as Boston West Hospital is performing above the national benchmark for patient satisfaction. The Boston West Hospital aim to continue its commitment in ensuring patients have a positive experience when they visit hospital and aim to build on the positive results experienced in 2014/15 during 2015/16 to maintain 100% patient satisfaction. 3.2 Patient Safety We are a progressive hospital and focussed on improving our performance in all aspects of the business, with a focus on 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 key performance indicators. 3.2.1 Infection Prevention and Control Boston West Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 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. At Boston West Hospital, this is demonstrated with our higher than average performance against national benchmarking data. 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. Page 30 of 42

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: The Boston West Hospital have a dedicated Infection Control Nurse who is responsible for the delivery of the Ramsay annual strategy for infection control. The annual plan is inclusive of training, audit, surveillance and screening programmes. Discussion of infection activity at the Infection Prevention and Control Committee, key items from the meeting are further disseminated through the medical advisory committee and clinical governance committee. A specific training module in respect of infection prevention and control is delivered on our induction programs, mandatory training and via an e-learning package, staff are required to be 100% compliant with their training. The dedicated infection control nurse attends the annual infection control and prevention conference to update on current practice and policy in relation to infection. The graph below shows the infection rates as a total percentage of the Boston West Hospital admissions. The graph demonstrates a 0.23% reduction in infections from the previous year. The decrease in infection rates could be attributed to better reporting of confirmed infections. In comparison to the national average the Boston West Hospital are performing above national benchmarks, demonstrating the infection prevention and control measures in place are effective. We aim to build on our positive work carried out in 2014/15 and progress this into 2015/16. Page 31 of 42

3.2.2 Cleanliness and Hospital Hygiene Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Boston West Hospital, providing us with a patient s eye view of the buildings, facilities and food we offer, giving us a clear picture of how the people who use our hospital see it and how it can be improved. The main purpose of a PLACE assessment is to get the patient view. The graph below shows the patient feedback from the most recent audit completed in 2014/15. Our 2014 PLACE highlighted a number of actions which we have now been implemented to improve the environment for our patients. The actions we have taken include a drop off point in the car park near the main entrance, a programme of redecoration, new seating and air conditioning in the patient waiting area, additional wheelchairs have been purchased for patient use and a new drinks machine has been placed in the patient waiting area, providing free hot and cold beverages for patients and visitors. The focus of PLACE in 2015 was to further develop a dementia friendly environment, with this in mind we have created better colour contrast in our patient toilets, installed dementia friendly signage and included large faced clocks, calendars and location signs in our pre-operative and recovery areas. Page 32 of 42