NEW HALL Hospital
Quality Account
2014-15
New Hall Hospital Quality Account 20142015
CONTENTS
Welcome to Ramsay Health Care UK
P3
Chief Executive officer statement
P3
Welcome to Ramsay New Hall Hospital
P4
Introduction to our Quality Account
P7
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
P8
1.2
Hospital accountability statement
P 10
PART 2
2.1
Priorities for Improvement
P 11
2.1.1
Review of clinical priorities 2014/15
P 11
2.1.2
Clinical Priorities for 2015/16
P 14
2.2
Mandatory statements relating to the quality of NHS services provided
P 187
2.2.1
Review of Services
P 17
2.2.2
Participation in Clinical Audit
P 19
2.2.3
Participation in Research
P 25
2.2.4
Goals agreed with Commissioners
P 26
2.2.5
Statement from the Care Quality Commission
P 27
2.2.6
Statement on Data Quality
P 27
2.2.7
Stakeholders views on 2013/14 Quality Accounts
P 31
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
P 42.
3.3
Clinical Effectiveness
P 48
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New Hall Hospital Quality Account 20142015
3.4
Patient Experience
P 49
3.5
Case Study
P 51
Appendix 1 – Services Covered by this Quality Account
P 54
Appendix 2 – Clinical Audits
P55
Welcome to Ramsay Health Care UK
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 32 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 and Clinical Commissioning Groups.
Chief Executive officer statement
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.
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New Hall Hospital Quality Account 20142015
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
Welcome to Ramsay New Hall Hospital
New Hall Hospital is part of the Ramsay Health Care Group and is an independent
hospital delivering a full range of specialist surgical and medical services. The hospital
is set in beautiful grounds and the original Georgian manor house now accommodates
three theatres and 32 beds with excellent physiotherapy and radiology services.
Consideration for our patients is at the heart of everything that we do.
We are constantly seeking new ways of working and bringing in fresh clinical practices
that will improve outcomes for our patients. Our approach to service delivery, which
includes working in partnership with the NHS, is courteous and professional and we
take great pride in our ability to innovate and look at new ways of working.
We provide fast, convenient, effective and high quality treatment for patients of all ages
(excluding children below the age of 18 years ) whether medically insured, self-pay, or
from the NHS.
We deliver a full range of specialist surgical and medical services (excluding cardiac
and neurosurgery) as inpatient and /or outpatient services to include
- General orthopaedics
- Spinal
- ENT
- Ophthalmology
- Maxillo facial
- Gynaecology
- Urology
- General surgery
- Colorectal surgery
- Cosmetic surgery
- Endoscopy
- General medicine to include neurology, cardiology and respiratory medicine
- Oncology
Patients requiring level 2 critical care are treated and cared for by appropriately trained
staff in a dedicated high dependency unit and the hospital has transfer arrangements in
place with the local trust and critical care network for level 3 care.
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New Hall Hospital Quality Account 20142015
In 2014/15 we treated 5943 patients as inpatients, of which 4395 were NHS patients
(74%) and 1548 were private patients (26%).
The staff to patient ratio is 1: between 5 and 8 (depending on patient dependence) and
there is an experienced Residential Medical Officer (RMO) on site 24 hours a day
New Hall follows the recommendations of the NICE safe staffing guideline: “Safe
staffing for nursing in adult inpatient wards in acute hospitals Report on the potential
resource implications”, published: July 2014 http://guidance.nice.org.uk.
This NICE guideline begins with recommendations for the responsibilities and actions at
an organisational level to support safe staffing for nursing in individual acute adult
inpatient wards. Although aimed primarily at the acute NHS setting we are committed to
attain equal safe staffing levels as recommended in this guidance.
The guideline also makes recommendations for monitoring and taking action according
to whether nursing staff requirements are being met and, most importantly, to ensure
patients are receiving the nursing care and contact time they need on the day. The
emphasis should be on safe patient care not the number of available staff and it is to
this that New Hall are committed for both patient safety and quality of care.
There is no single nursing staff-to-patient ratio that can be applied across the whole
range of wards to safely meet patients' nursing needs. Each ward or unit determines its
nursing staff requirements to ensure safe patient care.
We currently employ
-
Consultants (directly employed by Ramsay)
Consultants (with practicing privileges)
Registered Nurses
Operating Department Practitioners
Sterile Services Technicians
Radiographers
Physiotherapists
Health Care Assistants
Other Support Staff
Administrative staff
4
100 (all specialties)
44 + 8 bank
6 + 1 bank
4
4+ 3 bank
4+ 4 bank
18+2 bank
23 + 7 bank
51+ 7 bank
We provide outreach clinic services for outpatient NHS patients at Poole and
Dorchester hospitals for spinal services, and at Blandford clinic for general and spinal
orthopaedic services.
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New Hall Hospital Quality Account 20142015
We offer direct referral services for private cosmetic surgery and aesthetic cosmetic
treatments. All patients requiring NHS services are referred via their General
Practitioner (GP)
We have a dedicated GP liaison officer who has close contact with both the practice
managers and the GPs at practices throughout Wiltshire, Hampshire and Dorset. She
visits GP practices and organises regular “Lunch and learn” seminars and breakfast
meetings, taking Consultants into GP surgeries to offer training. In addition she also
runs regular Consultant led open evenings for GP’s.
We work closely with our local Clinical Commissioning Groups (Wiltshire, Hampshire,
and Dorset) to provide a range of surgical services within the standard acute contract.
We work closely with the Salisbury District Hospital who provides us with blood
transfusion, urgent pathology, histopathology and access to level 3 critical care
services.
We work closely with our community, holding regular charity events, such as coffee
mornings, cake sales, tombola to support local and national charities. A team of staff
have signed on to a charity run in July and will be sponsored. In addition, the Grand
Prize Draw at the Odstock, Nunton and Bodenham local village fairs are sponsored by
New Hall Hospital every year.
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New Hall Hospital Quality Account 20142015
Introduction to our Quality Account
This Quality Account is Ramsay New Hall hospital’s annual report to the public and
other stakeholders about the quality of the services we provide.
It presents our achievements in terms of clinical excellence, effectiveness, safety and
patient experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people we
treat.
It will also show that we regularly scrutinise every service we provide with a view to
improving it and ensuring that our patient’s treatment outcomes are the best they can
be.
It will give a balanced view of what we are good at and what we need to improve on.
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.
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New Hall Hospital Quality Account 20142015
Part 1 - Statement on quality
1.1: Statement from the General Manager
Welcome to New Hall Hospital’s quality account. This report outlines the Hospitals
approach to quality improvement, progress made in 2014-15 and plans for the
forthcoming year.
New Hall Hospital has five key values which underpin everything we do as an
organisation:
-
Put the patient first
Work as one team
Respect each other
Strive for continual improvement
Respect environmental sustainability
The aim of our Quality Account is to provide information to our patients and
commissioners to assure them we are committed to making progressive achievements.
For example, we participate in the Public Health England Surgical Site Surveillance
Service and Patient Reported Outcome Measures for Hip and Knee replacement,
hernias and varicose vein surgery.
Our emphasis is on ensuring patients receive safe, efficient and effective care, that they
feel valued, respected and involved in decisions about their care and are fully informed
about their treatment each step of the pathway.
The experience that patients have in our hospital is of the utmost importance and we
are committed to establishing an organisational culture that puts the patient at the
centre of everything we do. As well as being treated quickly and safely, our patients
receive a personalised service, enhanced by good communication and a commitment to
ensuring their privacy and dignity are respected at all times.
High quality patient care is at the centre of what we do and how we operate our
hospital. To do this we rely on excellent medical and clinical leadership plus an overall
continuing commitment to drive year on year improvement in clinical outcomes.
We especially value patient’s feedback about their stay, treatment and clinical outcome.
In the last year we have received excellent feedback from our internal and external
patient surveys. We have also participated in the patient NHS Friends and Family
Survey, and have been delighted with the many positive comments we have received.
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New Hall Hospital Quality Account 20142015
In 2014-2015 we underwent further significant refurbishment of rooms and were actively
in the planning stages for further redevelopment. This redevelopment will include:
•A Third Theatre with new expanded and extended recovery with a 12 bay Ambulatory
Unit
•Upgraded and relocated Minor Ops / Endoscopy Suite
•Expansion of the Outpatient Department
•Relocation of Physiotherapy with gym, linked to the Outpatient Department
•Re-housing admin staff and secretaries to purpose built accommodation.
•Addition of Conference Room,
•Extended Car-Park by 51 spaces.
The project has an anticipated completion date of May 2016.
New Hall Hospital continues to focus of delivering high standards of patient care in a
friendly and approachable manner. Working with our partners, who include local GPs,
Consultants and other specialists, we deliver our patients an individual, personal service
tailored to their needs.
Our patients can be assured of the quality of the hospital and its Consultants by
referring to the Care Quality Commission (CQC) Audits undertaken by the Department
of Health which support the hospital’s excellent reputation.
Fiona Taylor,
General Manager, New Hall Hospital
April 2015
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New Hall Hospital Quality Account 20142015
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.
Fiona Taylor
General Manager New Hall Hospital
Ramsay Health Care UK
May 21st 2015
This report has been reviewed and approved by:
MAC Chair: Mr Eunan Tiernan, Consultant Plastic Surgeon
Clinical Governance Committee Chair: Mr David Cox, Consultant Orthopaedic surgeon
Mr Stephan Andrejczuk, Ramsay Regional Director (South)
French Louise (NHS Wiltshire Clinical Commissioning Group);
Joanna Clifford (NHS West Hampshire Clinical Commissioning Group)
Susan O’Flanagan (NHS Dorset Clinical Commissioning Group)
May 21st 2015
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New Hall Hospital Quality Account 20142015
Part 2
2.1 Priorities for improvement
On an annual cycle, New Hall 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
2.1.1 Review of clinical priorities 2014/15 (looking back)
Three main quality indicator priorities were set for 2014/15 cover the domains of
patient safety, clinical effectiveness and patient experience
a) Patient Safety Quality Indicator:
As part of improving the patient experience and follow up support following
discharge from New Hall Hospital, New Hall was committed to ensuring patients had
ready access to support and advice from New Hall following discharge should it be
required and so during 2014-15.
This was a local CQUIN agreed with Wiltshire CCG and ensured that patients were
being discharged appropriately and with comprehensive follow up advice.
To this end, all Wiltshire NHS patients who had procedures as inpatients or as day
cases at New Hall during April and October 2014 were contacted at approximately
30 days following discharge.
The patients were asked whether they had attended their GP or the Accident and
Emergency department within 30 days of their New Hall procedure with a concern
directly related to that procedure.
A total of 115 patients were contacted by telephone and a response rate of 42% was
obtained.
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New Hall Hospital Quality Account 20142015
As a result of the initial survey, which indicated that some patients were still not clear
about whom to approach following discharge regarding concerns, we wanted to
empower patients with clear information about who to approach should they have
any post-operative queries or concerns following discharge home.
An action plan was put into place to address concerns that patients might not be
aware of the availability of access to care at New Hall following discharge.
Since discharge planning begins at preadmission, meetings were held with the
preadmission team to review patient discussion regarding follow up care and
pathways during the Pre-Assessment process.
All verbal and written information on post discharge care that was routinely given to
take home was reviewed and a clear pathway for contacting for patients to contact
New Hall first for all post-operative concerns was developed.
KIT cards (keep in touch card) were designed and ordered to give to patients on
discharge. This KIT card was a small credit card size card that the patient could
keep in their purse/wallet with clear contact details /hours for contacting New Hall,
and was designed to encourage patients to always contact New Hall first with any
concerns or queries if practicable.
Six months later, a second, similar survey was undertaken but in an attempt to get a
larger response; this survey was done as a simple postal survey with preaddressed
return envelopes.
In summary, the survey showed a clear 8% reduction in the number of patients
accessing primary and secondary emergency care following discharge between April
and October 2014 ,and the evidence suggested that a lack of clarity /communication
to patients at preadmission and on discharge had caused patients previously to not
initially contact New Hall with post - operative concerns/queries.
The October survey was reassuring in that it evidenced that only one patient six
months after the process had been changed, now felt he was unsure that he could
contact New Hall on discharge with post-operative concerns.
This quality initiative evidenced the importance of good communication with patients
throughout their whole care episode cycle and that patients welcomed giving
feedback about their post procedure care experiences.
It was a valuable tool to enable us to give ongoing best continuity of care to our
patients following discharge.
Since this patient safety initiative was achieved, it continues to be implemented
successfully as standard practice.
b) Clinical Effectiveness Quality Indicator:
Another quality improvement initiative in 2014/15 as part of improving clinical
effectiveness, New Hall was committed to reduce the number of avoidable re
admissions within 30 days of surgery.
It was planned that this would be monitored via NHS clinical indicators, which would
include readmission to other hospitals.
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New Hall Hospital Quality Account 20142015
The graph below shows that the number of readmissions within 30 days during
2013-14 was reduced from 0.5% in 2013/14 to 0.42% in 2014-15.
Readmissions
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
12/13
13/14
14/15
New Hall Hospital & NHS Treatment Centre
This trend will continue to be monitored via clinical governance and an ongoing aim
will be for it to reduce further although due to our increasing complexity of surgery, a
higher rate of readmissions than from 2012/13 is to be expected.
c) Patient Experience Quality Indicator:
During 2014-15, a quality initiative was set to increase the number of patients who
receive copies of their Consultant to GP letter.
This would ensure that patients could be kept fully informed regarding their care and
discharge. It was planned that compliance would be monitored via the QaR patient
questionnaire.
Looking back, the QaR data shows that a rolling year average of 84.9% of patients
stated that they received copies of the letters sent from the hospital to their GPs in
2014-15 compared to 82.5% in 2012-13. This indeed shows a small increase but the
trend continues to be reviewed via the QaR survey and will continue to be examined
during the next 12 months.
In addition, during 2014-15, we undertook to continue to improve the services
offered to patients to ensure they receive a positive experience. It was planned that
this be monitored via the patient questionnaire, the friends and family test and
through the “we value your opinion” leaflet.
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New Hall Hospital Quality Account 20142015
The scores from our main patient survey, the QaR patient satisfaction survey, show
consistent high levels of patient satisfaction within all areas for both 2013-14 and
2014-15 but moreover, the graph below shows the year improvement into 2014-15.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
93.0
95.8
2013/14
2014/15
20
0
New Hall Hospital
2.1.2 Clinical Priorities for improvement 2015/16(looking forward)
During 2015-16, the clinical priorities for New Hall will be linked into domains that
make up the NHS Outcomes Framework
Dementia Quality Indicator:
New Hall have set a quality indicator priority for 2015/16 to ensure we consistently
deliver safe, effective and patient centred care for patients with dementia who are
being cared for in all specialities within the hospital in both -patient and out-patient
settings, and on discharge from hospital to other providers. This indicator is linked to
domain 2 of the NHS Outcomes Framework - enhancing quality of life for people
with long term conditions.
This indicator was chosen in line with the Royal College of Nursing (RCN)
publication “Transforming Dementia Care in Hospitals 2013-14.”
In dementia care, the RCN recognises 5 key principles when supporting good
dementia care and New Hall wanted to meet these principles:
-
Staff who are skilled and have time to care
Partnership working with carers
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New Hall Hospital Quality Account 20142015
-
Assessment and early identification.
Care that is individualised
Environments that are dementia friendly.
We had also reviewing our previous services and reflected on our last dementia
PLACE review, we committed to engage with our Clinical Commissioners to put
forward with Dementia care as a clinical priority . New Hall has updated its
Dementia Strategy commitments and it is our intention to progress with actions
planned and report against progress against this strategy. Our main actions that we
are taking forward are:
-
Ensuring all relevant staff are trained in dementia awareness
Ensuring patients over the age of 75 will be screened for memory problems and
dementia at pre admission
Ensuring all staff will listen to the views and perspectives of carers and families
and take into account their expertise and knowledge
As far as practicable we will make the hospital environment as “dementia
friendly” as possible with appropriate signage.
A dementia friendly room will be designed and created that can be used
specifically to address the environmental needs of the patient with dementia.
Ensuring all staff will act as the patients advocate
Ensure that people with dementia are not prescribed medications, including antipsychotic medication unnecessarily or inappropriately
Ensure that people with dementia are supported at meal times and drink enough
fluids
Ensuring that people with dementia do not stay in hospital any longer than
necessary
An appointed dementia “champion” who is now in place on the ward will ensure
appropriate training and support for other staff members and act as a patient link.
Progress will be monitored via the Dementia Champion in conjunction with the
Matron and Quality Improvement manager.
Progress made and compliance will be evidenced by quarterly reporting to the CCGs
and Clinical Governance Committees, and an annual report published on the quality
account in April 2016.
Pressure ulcer prevention and Management
This quality priority indicator is linked to domain 5 of the NHS Outcomes Framework
-treating and caring for people in a safe environment & protecting them from
avoidable harm.
New Hall have set a quality indicator priority for 2015/16 to ensure we implement
best practice in the prevention , identification and management of any pressure ulcer
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New Hall Hospital Quality Account 20142015
events and to include working with the CCGs when we identify pressure ulcers
where New Hall has not been not the primary care giver.
Moreover, pressure ulcer prevention and management as a quality indicator was
prioritised after reviewing our services because although there were only small
numbers of Grade 2 pressure ulcers in 2014-15, the root cause analyses indicated
that improvements could be made in staff training in the risk assessing and
prevention of pressure ulcers.
Our aim will be to ensure all staff have annual refresher training awareness of
pressure ulcer prevention and management at mandatory refresher days as well as
implementing a more in depth up dated clinical training for clinical staff involved in
assessment, prevention and delivery of care in this field.
A pressure ulcer champion has been appointed, and a pressure ulcer awareness
notice board is available for staff reference. All pressure ulcers going forward will be
subject to root cause analysis with the objective of early organisational learning.
The hospital will maintain its links with the pressure ulcer clinic at the local trust for
shared learning.
Monthly and quarterly reports will be shared with the Commissioners and discussed
via the Clinical Governance Committee quarterly and an annual report published on
this quality indicator in April 2016 and an annual report published on this quality
indicator in April 2016.
Re-evaluation of our use of audit as a quality cycle tool.
This indicator is linked all 5 domains of the NHS Outcomes Framework
New Hall has set a quality indicator priority for 2015/16 to re-evaluate our use of
audit as a quality cycle tool.
This was set as a quality indicator priority because on self-review of our audits over
the previous year, it was decided that we were not using them as effective tools of
the quality improvement cycle.
Our aim will be to ensure that all staff have adequate audit training and become
confident and capable of undertaking audits and of using the audit cycle to reflect
and analyse problems or deficiencies in structures, or processes, or poor outcomes.
This will be co-ordinated by the Quality Improvement Manager who will complete
audit reports in conjunction with the auditors.
Quarterly audit reviews will be submitted to the clinical Governance committee and
an annual report published on this quality indicator in April 2016.
Organisational Learning and closing the loop
This indicator is linked to domains 1-3 (Effectiveness) of the NHS Outcomes
Framework.
In light of both the Francis and Keogh reports the recommendations identify the
importance of embedding a safety culture at the point of care and by reviewing our
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New Hall Hospital Quality Account 20142015
services internally, we have recognised that organisational learning and closing the
loop is an area for review and development.
We intend focus on our learning from the quantitative and qualitative data we gather
and make improvements to practice as a result of triangulation. We plan to report
quarterly on this quality initiative that would including themes, trends and actions to
prevent recurrences and to improve the quality of care delivered. An annual report
published on this quality indicator in April 2016.
Moreover, we will be very focused on looking forward and looking back at actions
recommended, actions taken, recommendations made and being able to close the
quality loop when appropriate and to evidence that we have done so.
2.2: Mandatory Statements relating to the quality of NHS services
provided
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 New Hall Hospital provided and /or subcontracted 7 NHS specialties
through the “Choose and Book “system.
New Hall 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 1 April 2014 to 31st March 15
represents 68.9% per cent of the total income generated from the provision of NHS
services by New Hall hospital for 1st April 2014 to 31st 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 benchmark against other hospitals and identifying key areas for improvement.
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New Hall Hospital Quality Account 20142015
In the period for 2014/15, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources
Staff Cost as % Net Revenue
29.5%
HCA Hours as % of Total Nursing
23.4%
Agency Cost as % of Total Clinical Staff Cost
5.9%
Ward Hours PPD
4.38
% Staff Turnover rolling 12 months
12.5%
% Sickness rolling 12 months
3.95%
% Lost Time
18.6%
Appraisal %
100%
Number of Significant Staff Injuries
0
Patient
Formal Complaints per 1000 HPD's
0.00152%
Patient Satisfaction Score
95.8%
Clinical Events per 1000 Admissions
0.0245
Readmission per 1000 Admissions
4
Quality
Workplace Health & Safety Score
98%
Infection Control Audit Score
92%
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New Hall Hospital Quality Account 20142015
2.2.2 Participation in Clinical Audit
National Audits
During 1 April 2014 to 31st March 2015, New Hall hospital participated in 100% of
the national clinical audits which it was eligible to participate in.
The national clinical audits proposed were agreed with the local CGC in advance.
Any audits not participated in were because we did not have enough relevant cases.
The Hospital was not eligible to participate in any of the National Confidential
Enquiries.
The national clinical audits that New Hall hospital participated in were completed
during 1 April 2014 to 31st March 2015 and are listed below.
Name
of
Review Programme
audit
/
Clinical
Outcome
% cases submitted
100% shoulders
100% knees
National Joint Registry (NJR)
99.1% hips
Elective surgery (National PROMs Programme)
76%
No cases
period
Severe sepsis & septic shock*
National Comparative Audit of Blood Transfusion programme
Medical and surgical clinical outcome review programme: National
confidential enquiry into patient outcome and death
in
Did not take part
Not enough cases
Not enough cases
Bowel cancer (NBOCAP)
Not enough cases
Head and neck oncology (DAHNO)
Not enough cases
Lung cancer (NLCA)
Not enough cases
Oesophago-gastric cancer (NAOGC)
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit
(NADIA)*
Falls and Fragility Fractures Audit Programme (FFFAP)
19
Not enough cases
Not enough cases
reporting
New Hall Hospital Quality Account 20142015
The reports of the two national clinical audits, the National Joint Registry and the
PROMS programme audit, for the period 1st April 2014 to 31st March 2015 were
reviewed by the local Clinical Governance Committee at the end of March 2015 and
New Hall Hospital intends to take the following actions to improve the quality of
healthcare provided:
To continue to improve our systems for submitting data and to continue to ensure all
patients are encouraged to complete the PROMS questionnaires and are aware the
reasoning behind this.
National Joint Registry (NJR)
New Hall Hospital continues to participate in the National Joint Registry (NJR) and a
screen shot and charts showing the submission volumes, consent rates and data
quality is displayed below.
Both rates continue to put the Ramsay Group well above the NJR KPI of 90%.
This information display shows whether this hospital is submitting all of the data they
should to the NJR (compliance), whether those records have corresponding patient
details (patient consent) and whether the records have a valid NHS or national
patient number. This is important so that the NJR can measure how long implants
last and look at other areas of surgical performance.
The display also shows a result for data entry delay. This indicates whether the
hospital is submitting their information in a timely way.
This is important so that the NJR can report an accurate and full picture of
performance to hospitals, the surgeons who work there as well as to patients and
the public.
Quality
Measure
Compliance (For the
Trust)
Consent
This
National
Hospital Expected
No Data Available
Better Than
-
-
100.0%
85.0%
99.3%
92.0%
23 Days
30 Days
Expected
Valid NHS number
Better Than
Expected
Time taken to enter
data
As Expected
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New Hall Hospital Quality Account 20142015
New Hall NJR Data for 1 April 2013 - 31 March 2014
Operation type
Operation sub category
Procedures recorded for
New Hall
National average
Hip Primary
201
99.1% submission rate
209
Hip Revision
18
99.1% submission rate
28
Knee Primary
Total knee replacement
195
100% submission rate
211
Knee Primary
Unicondylar Knee
Replacement
Fewer than 5
100% submission rate
21
Knee Revision
15 100% submission rate
17
Shoulder Primary
8
100% submission rate
437
14
Total
21
500
New Hall Hospital Quality Account 20142015
Elective surgery (National PROMs programme)
Patients undergoing elective inpatient surgery for four common elective procedures
(hip and knee replacement, varicose vein surgery and groin hernia surgery) funded
by the English NHS are asked to complete questionnaires before and after their
operations to assess improvement in health as perceived by the patients
themselves.
This involves asking patients to complete a questionnaire before their operation and
six-months after their operation.
These questionnaires are known formally as the National Patient Reported
Outcomes Measures (PROMs) programme.
They are designed to ask patients for their perspective on the effectiveness of care
they received in the NHS in England.
The Patient recorded outcome measures for New Hall patients are recorded below
for the reporting year 2014-15 and show outcomes which are higher than the
national average in both hip and knee primary revision surgeries.
In both groin hernia repairs and in revision hip replacement surgeries, numbers
were too low for comparison.
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New Hall Hospital Quality Account 20142015
Key Facts
April 2013 to March 2014, provisional data (published 13 February 2015)
Organisation level
Organisation name
Provider
NEW HALL HOSPITAL (NVC09)
England and Provider-level participation and coverage
There were 420 eligible hospital episodes and 319 pre-operative questionnaires returned - a headline participation rate of
76.0% (77.3% in England).
Of the 315 post-operative questionnaires sent out, 250 have been returned - a response rate of 79.4% (67.8% in England).
Adjusted average health gain
Figure 1: Adjusted average health gain on the EQ-5D TM Index by procedure
Adjusted average health gain
Adjusted average health gain (England)
Groin hernia (9)
Hip - primary (83)
Hip - revision (*)
Knee - primary (97)
Knee - revision (7)
Varicose vein (0)
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
Average adjusted health gain: EQ-5D IndexTM
Figure 2: Adjusted average health gain on the EQ-VAS by procedure
Adjusted average health gain
Adjusted average health gain (England)
Groin hernia (10)
Hip - primary (80)
Hip - revision (*)
Knee - primary (93)
Knee - revision (7)
Varicose vein (0)
-10.0
-5.0
0.0
5.0
10.0
15.0
20.0
Average adjusted health gain: EQ-VAS
Figure 3: Adjusted average health gain on the Oxford Hip Score
/ Oxford Knee Score by procedure
Adjusted average health gain
Adjusted average health gain (England)
Oxford Hip Score
Hip - primary (94)
Hip - revision (*)
Oxford Knee Score
Knee - primary (107)
Knee - revision (7)
0.0
5.0
10.0
15.0
20.0
25.0
Average adjusted health gain: Oxford Hip Score / Oxford Knee Score
Figure 4: Adjusted average health gain on the Aberdeen Varicose Vein
Questionnaire
23
Adjusted average health gain
Adjusted average health gain (England)
Varicose vein (0)
-18.0
-12.0
Improved
-6.0
0.0
6.0
Worsened
12.0
New Hall Hospital Quality Account 20142015
Local Audits
The reports of 70 clinical audits from 1 April 2014 to 31st March 2015 were
reviewed by the Clinical Governance Committee and New Hall hospital intends
to take the following actions to improve the quality of healthcare provided. The
clinical audit schedule for July 2014 to June 2015 can be found in Appendix 2.
Overall analysis: This audit period covers April 2014-end March 2015 and the
reporting period straddled the new annual auditing programme for the Ramsay
reporting year (July 2014 - June 2015.)
Good completion rates across the year were seen with just one audit not being
completed in a timely manner.
Some new audits had been introduced for the year (July 2014 - June 2015) and
the most significant change was the way in which the theatre audits were
divided out into new sections. Hence the theatre audit scores (July 201June
2015) are not directly comparable to those in the last audit year, apart from the
Surgical safety checklist audit which has shown a consistently high score.
The main compliance concern for the audit year July 2014 - June 2015 was that
whilst some audits had been completed, there was sometimes no follow through
from the previous audit, nor were there any narrative of actions completed. In
other cases, there were auditor names or dates in the relevant data fields.
This has been a concern in previous quarters and will now be taken forward as
a quality initiative for 2015-16 with actions including additional training and close
follow up of all audits with the auditor and the Quality Improvement manager
after every single audit.
The audit scores are flagged using a traffic light scoring system and during the
year, there were no overall traffic light red audit scores and most audits
remained in the green or cool amber brackets.
There were no other significant increasing or decreasing trends but some
variances were due to new auditors.
However, the challenge remains in 2015-16 for the audits to be used as true
tool of quality improvement rather than data collection and a focus will be
inputted towards this end.
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New Hall Hospital Quality Account 20142015
2.2.3: Participation in Research
There were no patients recruited during 2014/145 to participate in research
approved by a research ethics committee.
During 2015/16 a research Proposal has been put forward by a member of the
Nursing staff who is undertaking M.Sc. in Wound Healing and Tissue Repair at
Cardiff University, Wales.
The topic of this research will be
“A qualitative study to explore the patient’s experience of skin grafting/flap
following skin cancer resection.”
Despite increases in the number of people being diagnosed with skin cancer
each year the needs and experiences of people with skin cancer has received
little or no attention. Skin cancer is one of the most rapidly increasing cancers
among the fair-skinned populations world-wide (Vallejo-Torres et 2013). However
dystrophic skin scarring commonly occurs following skin cancer resections using
one of these methods (Andreassi et al 2005). In particular, the cosmetic outcome
of skin graft reconstructions, following carcinoma removal, is generally poor due
to wide marginal tumour excision, loss of subcutaneous tissues, and subsequent
pigmented atrophic scarring of the graft coverage (Migliano et al 2014).
Surprisingly little is known about the impact that skin grafting has on the patient.
This study seeks to investigate a number of areas to include; the patient’s
perspective of having a skin graft or flap, if they are adequately prepared for this
procedure and identify any gaps in the support that they may require.
The proposal has been submitted via the Ramsay New hall Clinical Governance
committee and Ramsay policy CN003 Research and Development Policy.
The MAC has been advised and has reviewed the proposal and is supportive of
the research project going ahead.
The project is still awaiting ethical approval from Cardiff University
=
Clinical practice innovation
The Preadmission Team had begun to use the new NICE guidance tool available
at www.preop.uk.This evidence of good practice was identified at the Clinical
compliance internal inspection visits 2014 and this practice was subsequently
shared across Ramsey for other sites to follow practice.
A patient participation group was established during 2014-15 and this is the
subject of the case study in section 3.4
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New Hall Hospital Quality Account 20142015
2.2.4: Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Ramsay New Hall’s income in from 1 April 2014 to 31st March
2015 was conditional on achieving quality improvement and innovation goals
agreed New Hall 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. Results: All
CQUINS 2014-15 were fully met.
The agreed CQUINS for 14/15 are listed below:
Dorset National CQUINS
1a-F&F-implementation of staff F &FT
1b-F&F Early implementation of F&F in OPD/Physiotherapy /Radiology
2-F&F-Increased or maintained response rate
3-F&F-Decreasing negative responses
2.1a-NHS safety thermometer-Reduction in Stage 2 pressure ulcers
2.1b- NHS safety thermometer-Prevalence of pressure ulcers
2.1c-Inherited pressure ulcers
2.1d -Participation in pressure ulcer working group
Dorset Local CQUINS
Catheter care bundle-urinary catheters-monthly audit 10 sets of notes
Establishing mental capacity at pre assessment-All patients >65 years
Peripheral vascular access device-monthly audit 10 sets of notes
Cauda equina monitoring-no of referrals, route of referrals and outcomes
Hampshire National CQUINS
1b-F&F Early implementation of F&F in OPD/Physiotherapy /Radiology
2-F&F-Increased or maintained response rate
2.1b- NHS safety thermometer-Reduction in Prevalence of pressure ulcers
Hampshire Local CQUINS
Improving patient experience-Work with group of patients to identify areas for
improvement-equality questionnaire
Outpatient follow up reform-review face to face follow up except where there is a
clear clinical rationale
Wiltshire National CQUINS
1a-F&F-implementation of staff F &FT
1b-F&F Early implementation of F&F in OPD/Physiotherapy /Radiology
2-F&F-Increased or maintained response rate
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New Hall Hospital Quality Account 20142015
3-F&F-Decreasing –negative responses
2.1a-NHS safety thermometer-Reduction in Stage 2 pressure ulcers
2.1b- NHS safety thermometer-Prevalence of pressure ulcers
2.1c-Inherited pressure ulcers
2.1d -Participation in pressure ulcer working group
Wiltshire Local CQUINS:
3. Outpatient Follow up ratio
4. Continuity of care: Number of Patients who have access to emergency primary
care (GP) and secondary care (A&E) after treatment at New Hall.
5. New Hall will implement a web based portal Patients will have the ability to
update medical records and complete Pre-Assessment medical questionnaires
The agreed CQUINS for April 1st 2015-31st March 2016 are available here
WILTSHIRE CQUIN
2015-16 PATIENT SAFETY.docx
WILTSHIRE CQUIN
2015-16 CLINICAL EFFECTIVENESS.docx
HAMPSHIRE CQUIN
2015-16 A SAFER SURGICAL PATHWAY.docx
DORSET CQUIN - A
Safer Surgical Pathway.docx
2.2.5: Statements from the Care Quality Commission (CQC)
New Hall Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March is registered without conditions.
The Care Quality Commission has not taken enforcement action against New
Hall Hospital during 2014/15
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New Hall Hospital Quality Account 20142015
New Hall hospital has not participated in any special reviews or investigations by
the CQC during the reporting period.
2.2.6: Statement on Data Quality
We regularly use statistical data to monitor clinical services
We are constantly reviewing this information by quality control initiatives.
Ramsay New hall Hospital continue to take the following actions to monitor and
to improve data quality
Medical records are audited monthly and action plans developed in response to
concerns as required.
New Hall Hospital has a data quality super user who manages the SUS pathway
and processes to ensure data quality as well as any electronic data audit
measures)
NHS Number and General Medical Practice Code Validity
Ramsay New hall submitted records during 2014/15 to the Secondary
Uses 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:
99.97% for admitted patient care
99.96% for outpatient care
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
Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall for
2014/5 was 75% and was graded ‘green’ (satisfactory).
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New Hall Hospital Quality Account 20142015
This information is publicly available on the DH Information Governance Toolkit
website at: https://www.igt.hscic.gov.uk
Clinical coding error rate
New Hall Hospital was not subject to the payment of results clinical coding audit
by the Audit Commission during 2014/15
New Hall hospital clinical coding department took part in an internal information
governance audit clinical coding in October 2014 and achieved the required 505
attainment level and the score achieved was the second highest Ramsay unit
score across the south.
Any actions required were immediately addressed the next audit is due in
October 2015.
The results were as below:
Ramsay Health Care
Information Governance Req 505 Clinical coding Attainment Levels Achieved March 15.docx
New Hall Clinical coding internal audit
October 2014
Result
Primary diagnosis
95.0%
Secondary diagnosis
98.5%
Primary Procedure
98.3%
Secondary Procedure
100%
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New Hall Hospital Quality Account 20142015
2.2.7: Stakeholders views on 2014/15 Quality Account
Copies of this report have been sent internally to:

MAC Chair: Mr Eunan Tiernan, Consultant Plastic Surgeon

Clinical Governance Committee Chair: Mr David Cox , Consultant Orthopaedic
surgeon

Mr Stephan Andrejczuk, Ramsay Regional Director (South)
Copies of this report have been sent externally to:

French Louise (NHS Wiltshire Clinical Commissioning Group);

Joanna Clifford (NHS West Hampshire Clinical Commissioning Group)
Quality Account
review WHCCG.pdf

Susan O’Flanagan (NHS Dorset Clinical Commissioning Group)
30
New Hall Hospital Quality Account 20142015
Part 3: Review of quality performance 2014/2015
Statement from Director of Clinical Services, Ramsay Health Care UK:
“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
Statement from Matron, New Hall hospital Ramsay Health Care UK:
I am delighted to be able to contribute to the New Hall quality account for 14/15. As
Matron my main focus is to ensure patients receive safe and effective care, that they
are treated with care and compassion, feel valued and respected in decisions about
their care and are fully informed and involved in their treatment at each stage of their
pathway. High quality patient care is at the centre of everything we do and how we
operate our hospital. To do this we rely on an excellent team at New Hall who are
committed, dedicated and competent and who share the same values and practice
according to the Ramsay way. We also need medical and clinical leadership plus an
overall continuing commitment to drive year on year improvement in clinical outcomes.
Deborah Stott, Matron, New Hall Hospital, Ramsay Health Care UK
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New Hall Hospital Quality Account 20142015
Ramsay Health Care Clinical Governance Framework 2014:
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
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New Hall Hospital Quality Account 20142015
Clinical Governance Framework model:
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.
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New Hall Hospital Quality Account 20142015
3.1 The Core Quality Account indicators
Hospitals are required to include indicators in their Quality Accounts relevant to
the services they provide.
Mortality
The mortality quality indicator is related to the NHS Outcomes Framework
Domains Preventing People from dying prematurely and Enhancing quality of life
for people with long-term conditions.
The data made available to the National Health Service trust or NHS foundation
trust by the Health and Social Care Information Centre with regard to:
(a) The value and banding of the summary hospital-level mortality indicator
(“SHMI”) for the trust for the reporting period April 1st 2014 - 31st March 2015
and
(b) The percentage of patient deaths with palliative care coded at either
diagnosis or specialty level for the trust for the reporting period April 1st 2014 31st March 2015:
New Hall Hospital considers that this data is as described for the following
reasons:
There are very few deaths at, or following treatment at this hospital.
New Hall Hospital intends to take the following actions to maintain / improve this
rate and so the quality of its service
-
Maintain a safe and efficient pre assessment service to ensure patients
are optimised prior to surgery.
Ensure all staff are appropriately trained and assessed.
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New Hall Hospital Quality Account 20142015
Re-admissions
The readmissions quality indicator is related to the NHS Outcomes Related NHS
Outcomes Framework Domain 3: Helping people to recover from episodes of ill
health or following injury
Data regarding patients readmitted to a hospital which forms part of the trust,
within 28 days of being discharged from a hospital, which forms part of the trust
,during the reporting period April 1st 2011 - 31st March 2012.
New Hall Hospital considers that this data is as described for the following
reasons:
-
New Hall hospital has a significantly high complexity factor and has an
active policy of readmitting patients rather than redirecting them to other
sites.
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service:
-
Maintain a comprehensive discharge process with appropriate post
discharge information and support.
To continue to monitor admissions to other sites
PROMS
The PROMS quality indicator is related to the NHS Outcomes Related NHS
Outcomes Framework Domain3: Helping people to recover from episodes of ill
health or following injury.
The data made available to the National Health Service trust or NHS foundation
trust by the Health and Social Care Information Centre with regard to the trust’s
patient reported outcome measures scores for the reporting period April 1st 2014
- 31st March 2015:
(i)
Groin hernia surgery
(ii)
Varicose vein surgery
35
New Hall Hospital Quality Account 20142015
(iii)
Hip replacement surgery
(iv)
Knee replacement surgery
Hernia
PROMS:
Period
Hernia Apr13 - Mar14
Apr14 - Sep14
Best
NT415
0.139
RXR
0.125
Worst
NVC11
0.008
Several
0.009
Average
Eng
0.085
Eng
0.081
Period
Apr13 - Mar14
Apr14 - Sep14
New Hall
NVC09
*
NVC09
*
New Hall Hospital considers that this data is as described for the following
reasons
-
The number of hernia procedures is too small for New Hall to participate
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
-
It will ensure all patients undergoing this procedure are offered the opportunity to
undertake this measure and participate if numbers are sufficient
Veins
PROMS:
Period
Veins Apr13 - Mar14
Apr14 - Sep14
Best
RTH
RYJ
11.292
-4.567
Worst
NT350 -16.849
RWA
-16.762
Average
Eng
-8.698
Eng
-9.479
Period
Apr13 - Mar14
Apr14 - Sep14
New Hall
NVC09
NVC09
New Hall Hospital considers that this data is as described for the following
reasons:
-
The number of vein procedures is too small for New Hall to participate
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
-
It will ensure all patients undergoing this procedure are offered the opportunity to
undertake this measure and participate if numbers are sufficient
Hips
PROMS:
Period
Hips Apr13 - Mar14
Apr14 - Sep14
Best
NT441
24.444
RCB
25.418
Worst
RQX
17.634
RJD
18.357
36
Average
Eng
21.34
Eng
21.922
Period
Apr13 - Mar14
Apr14 - Sep 14
New Hall
NVC09
22.754
NVC09
*
New Hall Hospital Quality Account 20142015
-
New Hall Hospital considers that this data is as described for the following
reasons:
Patients reporting good outcomes when completing their post op questionnaire.
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service:
-
To continue to improve return rates
Knees
PROMS:
Period
Knees Apr13 - Mar14
Apr14 - Sep14
Best
NT404
19.762
RWP
20.44
Worst
NV323
12.049
RXF
14.416
Average
Eng
16.248
Eng
16.702
Period
Apr13 - Mar14
Apr14 - Sep14
New Hall
NVC09
17.785
NVC09
*
New Hall Hospital considers that this data is as described for the following
reasons:
-
Patients reporting good outcomes when completing their post op questionnaire
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
-
To continue to improve return rates
Responsiveness to personal care
Responsiveness:
Period
Best
Worst
Average
Period
New Hall
to personal
2012/13
RPC
88.2
RJ6
68.0
Eng
76.5
2013/14
NVC09
90.9
needs
2013/14
RPY
87.0
RJ6
67.1
Eng
76.9
2014/15
NVC09
91.0
The responsiveness to personal care quality indicator is related to the NHS
Outcomes Related NHS Outcomes Framework Domain: Ensuring that people
have a positive experience of care.
The data made available with regard to the trust’s responsiveness to the
personal needs of its patients during the reporting period April 1st 2014 - 31st
March 2015
New Hall Hospital considers that this data is as described for the following
reasons:
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New Hall Hospital Quality Account 20142015
-
We ensure all staff are aware of the need for excellent customer service
Care planning is individualised and takes into account the holistic needs of the
patient.
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
-
To ensure patients’ needs are at the forefront of everything we do.
To continue to learn from our patient feedback, compliments and complaints and
from them gain organisational learning that we will share.
VTE
VTE Assessment:
Period
14/15 Q2
14/15 Q3
Best
Several
100%
Several
100%
Worst
RNL
86.4%
NT322
85.1%
Average
Eng
96.2%
Eng
96.0%
Period
14/15 Q2
14/15 Q3
New Hall
NVC09
99.8%
NVC09
99.8%
The VTE quality indicator is related to the NHS Outcomes Related NHS
Outcomes Framework Domain 5: Treating and caring for people in a safe
environment and protecting them from avoidable harm.
The data made available to the National Health Service trust or NHS foundation
trust by the Health and Social Care Information Centre with regard to the
percentage of patients who were admitted to hospital and who were risk
assessed for venous thromboembolism during the reporting period April 1st 2014
- 31st March 2015:
New Hall Hospital considers that this data is as described for the following
reasons
-
All clinical staff are aware of the need for VTE assessment
Clinical care pathways direct the staff member to ensure completion
Excellent communication with Consultants to ensure compliance.
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
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New Hall Hospital Quality Account 20142015
-
To ensure patients’ VTE requirements are assessed and patients receive
appropriate prophylaxis
C. Difficile rates per 100,000 bed days
C. Diff rate:
Period
Best
Worst
Average
Period
New Hall
per 100,000
2012/13
Several
0
RVW
30.8
Eng
17.4
2012/13
NVC09
0.0
bed days
2013/14
Several
0
RMP
32.5
Eng
14.7
2013/14
NVC09
0.0
The c. difficile quality indicator is related to the NHS Outcomes Related NHS
Outcomes Framework Domain 5: Treating and caring for people in a safe
environment and protecting them from avoidable harm.
The data made available to the National Health Service trust or NHS foundation
trust by the Health and Social Care Information Centre with regard to the rate per
100,000 bed days of cases of C difficile infection reported within the trust
amongst patients aged 2 or over during the reporting period April 1st 2014 - 31st
March 2015:
New Hall Hospital considers that this data is as described for the following
reasons
-
We have a good record in infection prevention and control
Antimicrobial prescribing is in line with Ramsay policy and CCG formulary
Incident rate, Patient safety
The incident rate (patient safety) quality indicator is related to the NHS Outcomes
Related NHS Outcomes Framework Domain 5: Treating and caring for people in
a safe environment and protecting them from avoidable harm.
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New Hall Hospital Quality Account 20142015
The rate of patient safety incidents reported within Ramsay New Hall during the
reporting period April 1st 2014 - 31st March 2015, and the number and
percentage of such patient safety incidents that resulted in severe harm or death.
New Hall Hospital considers that this data is as described for the following
reasons
-
We provide elective and non-emergency elective care for spinal patients
with significant co-morbidities.
There is an effective pre admission process to ensure patient’s condition
is optimised prior to surgery
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
-
To continue ensure all patient safety incidents are reviewed and analysed
to identify areas of concern and action plan as required
Ensure patients are treated in a safe and comfortable environment and
that staff are responsive to their needs.
Friends and Family Test
F&F Test:
Period
Jan-15
Feb-15
Best
Several
100%
Several
100%
Worst
RPA02
51.2%
RHU10
75%
Average
Eng
94.0%
Eng
94.7%
Period
Jan-15
Feb-15
New Hall
NVC09
100.0%
NVC09
98.0%
The Friends and family quality indicator is related to the NHS Outcomes Related
NHS Outcomes Framework Domain 4: Ensuring that people have a positive
experience of care.
The Friends and Family inpatient scores reported within Ramsay New Hall during
the reporting period April 1st 2014 - 31st March 2015:
New Hall Hospital considers that this data is as described for the following
reasons
-
Actively encourage patients to undertake the friends and family test
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New Hall Hospital Quality Account 20142015
-
-
The test has now been expanded to outpatients (to include radiology and
physiotherapy) to gain an overall picture of the hospital rather than just
inpatients.
New Hall Hospital intends to take the following actions to improve this rate and
so the quality of its service
To continue to encourage patients to take the test
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. Triangulation
reports/Organisational learning
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
Infection prevention and control
New Hall hospital has a very low rate of hospital acquired infection and has had
no reported MRSA Bacteraemia in the past 6 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
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New Hall Hospital Quality Account 20142015
A network of specialist nurses and infection control link nurses operate across
the Ramsay organisation to support good networking and clinical practice.
Infection Rates
Infection Rates
(percentage of Admissiosns)
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2012/13
2013/14
2014/15
New Hall Hospital
As shown in the graph our infections rates remain very low and are reducing year
on year despite accepting more complex patients and non-elective nonemergency cases. As a unit we have secured more hours for infection control
issues following a restructuring of our senior nursing team. We have been
working towards annual ANTT assessments locally in all relevant clinical areas
for IV insertion and administration, hand washing, catheter insertion and
management and wound management. This has served to raise the profile of
ANTT system across the hospital. The ICLN is now based on the ward and is
more visible in clinical areas so is on hand to advise and if necessary correct
practice for all staff. Audits of consultant practice have also been undertaken in
Radiology OPD practice and Theatres and where necessary advice and
feedback given.
We have refreshed the annual mandatory training and we pick new issues to
highlight annually. The past years focus has been HCAI’s and the Chain of
Infection [highlighting the role of correct hand washing in reducing incidence].
The focus will change in the next quarter to Antibiotic stewardship, Isolation
practices and environmental cleaning. We also have a series of training forums
planned for SEPSIS/SIR’s identification and management; SSI management and
auditing; The body’s response to infection; Common micro-organisms, their
spread and management; Environmental cleaning, managing body fluid spills,
waste management and linen disposal.
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New Hall Hospital Quality Account 20142015
Clinical auditing is carried out throughout the year on a rolling programme:
1. Monthly catheter management audits are undertaken by ward staff.
2. Environmental audits 3 monthly covering: decontamination, sharps handling
and disposal, waste management and disposal, General environment condition
and cleanliness, clinical equipment management and condition, clinical practice
and spot hand washing/decontamination.
3. Four monthly- Hand washing/decontamination.
4. Bi-annually – Surgical Site Infection, Peripheral Venous Cannula Care Bundle,
Central Venous Care Bundle and Catheter Care Bundle.
5. Annually – Isolation and external waste management and Sharps disposal.
In addition Pharmacy carry out bi-annual medical management and records
audits incorporating antibiotic prescribing. Corporately we also carry out annual
point prevalence surveillance on peripheral line care bundles and catheter care
bundles.
We have audited our use of catheters and the cleaning of equipment locally
against EPIC 3 guidance and recommendations for changes to our current
products are with our corporate ICC for authorisation.
We are taking a much more robust approach to managing infections both by
changes to the way we collect data pertaining to infections and in our follow-up of
management [especially in relation to antimicrobial stewardship] and root causes.
Work is ongoing with regards to hand washing both for staff and patients and
visitors. We have an awareness day planned for October where our supplier is
coming in to provide information to both staff and visitors with regards to hand
hygiene. We have reviewed our posters locally, improved our hand hygiene
literature for patients and are working towards better promotion of the use of gel
by both staff and visitors by better signage [ especially related to isolation rooms]
and encouraging patients/visitors to carry out hand hygiene at appropriate times.
The WHO 5 moments of hand hygiene is actively being promoted to all.
Infection control programmes and activities within our hospital include:
-
-
Comprehensive infection control programme of staff education and competency
assessments including Aseptic Non Touch Technique (ANNT).
Strict adherence to Ramsay .uniform policy for all staff including bare below
elbows for all Consultant staff.
Hand gel dispensers are available at the end of every patient bed and
instructions on how to the use the gel correctly displayed.
The hospital has an Infection Control Committee led by a Consultant
Microbiologist. This meets quarterly and reports to the Clinical Governance
Committee and corporate infection control committee.
Spots checks on all staff of hand hygiene practice using a UV light box.
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New Hall Hospital Quality Account 20142015
-
A regular programme of audit covering all aspects of infection control as well as
spot checks on cleaning practices by the Senior Management Team.
Cleanliness and hospital hygiene
One way in which safe healthcare environments are assessed includes PatientLed Assessments of the Care Environment (PLACE). The main purpose of a
PLACE assessment is to get the patient view.
PLACE assessments occur annually at New Hall 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 chart below demonstrates the year on year improvement in the domain of
cleanliness and the increase in score above the national average for 2014.
PLACE
results Cleanliness score
2014-15
Newhall Hospital 93.71%
2013
National Average 96.89%
2014
Newhall
2014
Hospital 97.25%
Comments
This is both above the national average
and also significantly above the
cleanliness score in the 2013 PLACE
audit.
The chart below shows the remaining three domains of the assessment against the
National average score for this domain in the 2014 PLACE audit:
Domain
National
average
score
2014
New Hall Comments
score
2014
Food
and
Hydration
88.79%
90.21%
This score is above the national average and
action taken was to feedback this score to the
catering department, to the Customer Quality
Team and to all staff. The score will continue to be
monitored during 2015-16 year.
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New Hall Hospital Quality Account 20142015
Privacy,
Dignity and
Wellbeing
87.73%
75.76%
The domain of privacy, dignity and wellbeing score
was the key concern for the PLACE audit of 2014.
The score was well below the national average as
well as being well below the score in the 2013
PLACE audit.However, due to changes in
methodology in the PLACE assessments between
2013 and 2014, comparisons between 2014 and
2013 are not possible for the Privacy Dignity and
Wellbeing, food and hydration scores.
The assessment for Privacy, Dignity and wellbeing
includes infrastructural/organisational aspects –
the extent to which the environment supports the
delivery of care with privacy and dignity. Areas
such as provision of outdoor/recreation areas,
changing and waiting facilities, access to
television, radio, computers and telephones were
reviewed and in addition, practical aspects such
as appropriate separation of sleeping and
bathroom/toilet facilities for single sex use,
bedside curtains being sufficient in size to create
private space around bed sand ensuring patients
are appropriately dressed to protect their dignity,
were looked at.
The 2014 report for privacy dignity and well-being
assessment criteria was particularly around
access to television and radio which meant the
scores for 2013 and 2014 were not directly
comparable. However, the fact that the New Hall
score of 75.76% is significantly below the national
average of 87.73% is a benchmark concern and
thus
needed
to be examined closely and
conclusions and actions for this result planned .
The ongoing and outstanding refurbishment
programme of the Clock House and theatres due
in 2015/16 will seek to address many of the
concerns.
Actions taken were to feedback this score to the
Customer Quality Team, the SMT and to all staff.
The score will continue to be monitored during
2015-16 year.
Condition
Appearance
and
Maintenance
95%
91.97%
This score was also below the national average
but significantly above the score in the 2013
PLACE audit.
The ongoing refurbishment programme accounted
for the score improvement between 2013-14 and
the outstanding refurbishment of the Clock House
and theatres due in 2015/2016 also accounted for
the score remaining below the national average at
this time. Actions taken were to feedback to all
staff and discuss privacy and dignity requirement
in the care environment with refurbishment project
managers
.
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New Hall Hospital Quality Account 20142015
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 the General Manager and Matron which ensures we
keep up to date with all safety issues.
All incidents remain recorded in a timely manner on Ramsay electronic risk
reporting system (Risk man) and are reviewed and analysed by the senior
management team, at Clinical Governance and at health and safety meetings.
Actions plans are developed in response to concerns raised and shared with
appropriate staff.
Features installed in the previous year remain very effective in enhancing
security and safety within the workplace: CCTV is covers all external areas of the
hospital.
An automatic bed pusher remains in use to assist with manual handling.
Staff undergo a comprehensive programme in manual handling activities, fire and
security awareness.
All patients’ beds are now electric allowing greater control for staff and patients
and reducing the need for manual handling.
The Health and Safety Committee met bi-monthly in accordance with corporate
policy and follow the corporate agenda.
A Health, Safety & Facilities Audit is completed annually.
A score of 98% was achieved on the 8/1/15. New Hall hospital regularly reviews
the action points from the audit and document/update progress. New Hall
Hospital exceeded the 95% compliance set by the group for 2014.
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New Hall Hospital Quality Account 20142015
The Risk Management/Health and Safety committee met bimonthly and all
Departments were represented.
There were 6 Risk Management/Health and Safety committee meetings in the 12
month period with full reporting on the outcomes and actions of the committee, all
of which were communicated and feedback to the hospital staff is disseminated
through Health and safety minutes, Heads of Department meetings and Clinical
Governance reviews and minutes/bulletins.
Key safety achievements of year 2014-15
Summarised below are the key health and safety achievements of 2014-15
period:
-
New Stand by Generator installed
-
UPS IPS installed for theatres & HDU
-
Slips, trips and falls leaflets in all patients Pollards (CL-3657-000-R)
-
Car-park uneven surfaces pot holes filled ongoing monthly checks
-
Legionella assessment actions completed OPD new system installed
-
Upgraded Oil tank
-
Improved emergency lighting
-
Installed DDA compliant Main Reception desk
-
Installed DDA toilet facilities
-
All lifts motor equipment refurbished
-
Upgraded nurse call
-
Longford Ward Corridor lightning upgraded
-
Maintenance/porters received training lift entrapment
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New Hall Hospital Quality Account 20142015
3.3: Clinical effectiveness
New Hall Hospital has a Clinical Governance team and committee that meet
quarterly through the year to monitor quality and effectiveness of care.
Clinical incidents, patient and staff feedback are systematically reviewed to
determine any trend that requires further analysis or investigation.
More importantly, recommendations for action and improvement are presented to
hospital management and Medical Advisory Committees to ensure results are
visible and tied into actions required by the organisation as a whole
Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure.
Every surgical intervention carries a risk of complication so some incidence of
returns to theatre is normal. The value of the measurement is to detect trends
that emerge in relation to a specific operation or specific surgical team. Ramsay’s
rate of return is very low consistent with our track record of successful clinical
outcomes.
As can be seen by the graph below, the number of returns to theatre has
reduced significantly from 2013/14 and from 2012/13, despite increasing
complexities of the procedures undertaken.
All returns to theatre are entered onto Risk man and analysed for trends by the
Quality Improvement Manager and the Clinical Governance team.
All returns to theatre will continue to be monitored and actions taken as required.
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New Hall Hospital Quality Account 20142015
Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2012/13
2013/14
2014/15
New Hall Hospital
3. 4: Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
-
Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their
web survey
Yearly CQC patient surveys
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New Hall Hospital Quality Account 20142015
-
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/emails
Patient focus groups
PROMs survey
Care pathways – patient are encouraged to read and participate in their
plan of care
Patient Satisfaction Survey
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 (inpatient or outpatient) is asked their consent to receive an
electronic survey or phone call after they leave 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.
As can be seen in the graph below our patient satisfaction rate has increased by
2.8% and remains very good.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
93.0
95.8
2013/14
2014/15
20
0
New Hall Hospital
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New Hall Hospital Quality Account 20142015
3.4: New Hall Hospital Case Study: Patient participation group
We are committed to continuing to engage with patients, staff, Consultants and
other relevant stakeholders to continually improve the quality of service we
provide and patient experience. Thus in 2014-15, in order to understand what we
can do better from a patient perspective we set up a Patient participation group.
This was a CQUIN agreed with West Hampshire NHS Commissioning Group for
2014-15.
The Objectives were:
a. To develop an approach to improvement of the patient experience by the
development of a patient participation group.
b. To ensure that the views of a diverse patient population are representative
in each group.
c. To address improvements specifically identified by the patients
themselves following in or outpatient experience at New Hall
d. To develop actions and objectives from these patients led suggested
improvements.
e. To create a pathway and terms of reference for such a patient
participation group.
f. To explore different methods of engagement of service users -phone/email, text, face to face, group.
g. To inform the Patients of the aim of the patient participation group and
gain a group of patients who would be willing to participate.
h. To contact Patients to invite them to a patient participation group stating
clear objectives.
i. To create a meeting agenda.
j. To determine how the Patient feedback will be gathered from the meeting,
looking at patient experiences, comments and suggestions, and critically
analyse them after the meetings.
k. To ensure that all significant risks relevant to the Committee’s areas of
responsibility previously not identified to the hospital are identified and
reported to SMT.
l. To advise the Business upon ways to implement the suggested quality
improvements whilst maintaining the optimum level of quality and
efficiency in the delivery of patient care at New Hall.
m. To identify any areas for improvement identified by patients that cannot be
resolved imminently, with a reason for the non-inclusion of an action for
improvement.
n. To follow up and progress improved quality recommendations via SMT.
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New Hall Hospital Quality Account 20142015
o. To ensure care and service improvements suggested and implemented
are measured are based on objective measurement of outcomes and
clinical data.
Implementation was done by:
a. Creation of a vision of a Patient Participation group with clear terms of
reference.
b. Different methods of engagement of service users were considered: phone/e-mail, text/face to face.
c. The inclusion of a diversity survey was planned to be to be mandatory
d. The group was designed to be a focused patient group – patients would
identify a range of areas which would improve the patient experience ,
establishing a baseline of patient views (before improvements)
e. Recommendations were to be reviewed and followed up and actions
monitored and reported to Customer Quality Team
f. A focused patient survey – establishing a baseline of patient views (after
improvements)
g. Any areas identified by patients but not included in action plan should be
rationalised with reasons for the non-inclusion in actions going forward.
Actions produced from this feedback included:
a. An action plan was produced and discussed with the Customer Quality
Team and with the matron and Heads of Department. Changes of practice
were initiated from this including a change of practice that patients who
were nervous could request that a family member /friend could stay with
them in the direct admission unit immediately between admission and
transfer to theatre.
-+
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New Hall Hospital Quality Account 20142015
Appendix 1: Services covered by this quality account
Regulated Activities – New Hall Hospital:
Treatment
Disease,
Disorder
Or injury
Surgical
Procedures
Diagnostic
and
screening
Family
Planning
Services
of
Services Provided
Bariatrics, Dermatology, General medicine, Neurology,
Oncology, Pain management, Physiotherapy, Psychiatry
(outpatients only), Psychology, Orthopaedic medicine,
Rheumatology, Sports Medicine
Satellite Out patient services being carried out at Dorset
County Hospital and Poole Hospital for Dorset PCT
Outreach clinics at Blandford Community Hospital for
spinal and orthopaedic consultation.
Bariatrics, Cosmetics, Dermatology, Ear, Nose and
Throat (ENT), Gastrointestinal, General surgery,
Gynaecology,
Ophthalmic,
Orthopaedic,
Oral
maxillofacial, Urological, Ambulatory, Day and Inpatient
Surgery
GI physiology, Imaging services, Phlebotomy,
Endoscopy, Urinary, Urodynamics, Screening and
Specimen collection. Satellite Outpatient services
carried out at Dorset County Hospital and Poole
Hospital for Dorset PCT
Gynaecology patient pathway, insertion and removal of
inter uterine devices for medical as well as
contraception purposes
53
Peoples Needs Met for:
All adults 18 yrs and over,
All adults 18 yrs and over, excluding:

Patients with blood disorders (haemophilia, sickle cell,
thalassaemia)

Patients on renal dialysis

Patients with history of malignant hyperpyrexia

Planned surgery patients with positive MRSA screen
are deferred until negative

Patients who are likely to need ventilatory support
post operatively

Patients who are above a stable ASA 3.

Any patient who will require planned admission to ITU
post surgery

Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or dyspnoea at
rest)

Poorly controlled asthma (needing oral steroids or has
had frequent hospital admissions within last 3 months)

MI in last 6 months

Angina classification 3/4 (Limitations on normal
activity e.g. 1 flight of stairs or angina at rest)

CVA in last 6 months BMI >340 (non bariatrics)
However, all patients will be individually assessed and we
will only exclude patients if we are unable to provide an
appropriate and safe clinical environment.
All adults 18 yrs and over, s
All adults 18 years and over as clinically indicated
New Hall Hospital Quality Account 20142015
Appendix 2:
Copy of New Hall Hospital Audit programme 2015/16.
54
New Hall Hospital Quality Account 20142015
New Hall Hospital
Ramsay Health Care UK
We would welcome any comments on the format,
content or purpose of this Quality Account.
If you would like to comment or make any suggestions
for the content of future reports, please telephone or
write to the General Manager using the contact details
below.
For further information please contact:
01722 422333 ext 140
www.newhallhospital.co.uk
55