Cobalt Hospital
Quality Account
2013/14
Contents
Welcome to Ramsay Health Care UK
4
Introduction to our Quality Account
5
PART 1 – STATEMENT ON QUALITY
6
1.1
Statement from the General Manager
6
1.2
Hospital Accountability Statement
7
1.2.1 Cobalt Hospital
8
PART 2
9
2.1
9
Priorities for Improvement
2.1.1 Review of Clinical Priorities 2013/14 (looking back)
9
2.1.2 Clinical Priorities for 2014/15 (looking forward)
11
2.2
Mandatory statements relating to the quality of NHS services
provided
13
2.2.1 Review of Services
13
2.2.2 Participation in Clinical Audit
14
2.2.3 Participation in Research
15
2.2.4 Goals agreed with Commissioners
15
2.2.5 Statement from the Care Quality Commission
15
2.2.6 Statement on Data Quality
15
2.2.7 Stakeholders views on 2013/14 Quality Accounts
17
PART 3 – REVIEW OF QUALITY PERFORMANCE
18
3.1
The Core Quality Account indicators
20
3.2
Patient Safety
23
3.3
Clinical Effectiveness
26
3.4
Patient Experience
27
3.5
Case Study
29
Appendix 1 – Services Covered by this Quality Account
30
Appendix 2 – Clinical Audits
31
Welcome to Ramsay Health Care UK
Cobalt Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group, was established in 1964 and has grown to become
a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay
Health Care is one of the leading providers of independent hospital services in
England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of
NHS patient episodes of care each month working seamlessly with other healthcare
providers in the locality including GPs and Clinical Commissioning Groups.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is our number one goal. This relies not only on excellent
medical and clinical leadership in our hospitals but also upon an organisation wide
commitment to drive year on year improvement in patient satisfaction and clinical
outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is not
about reliance on one person or a small group of people to be responsible and
accountable for our performance. It is essential that we establish an organisational
culture that puts the patient at the centre of everything we do and as a long standing
and major provider of healthcare services across the world, Ramsay has a very
strong track record as a safe and responsible healthcare provider and we are proud
to share our results.
Across Ramsay we nurture the teamwork and professionalism on which excellence
in clinical practice depends. We value our people and with every year we set our
targets higher, working on every aspect of our service to bring a continuing stream of
improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2013/14
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Introduction to our Quality Account
This Quality Account is Cobalt 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 did not
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.
Quality Accounts 2013/14
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Part 1
1.1 Statement from the General Manager
“Cobalt Hospital is committed to being a leading provider of outpatient,
diagnostic and day case services by delivering high quality outcomes and an
excellent patient experience.”
I am delighted to introduce our Quality Account for 2013/14 which demonstrates our
commitment to delivering high quality care. The report focuses upon our
performance over the last year and describes our priorities for 2014/15.
Our approach to quality is having in place a robust framework which enables us to
monitor and measure outcomes and experience, using this information to drive
further improvement in patient safety, patient experience and clinical outcomes. Our
team is at the forefront of delivering a quality service. “People caring for people”
remains our philosophy and we are committed to training and developing our
workforce and ensuring attitudes and behaviour aligned to our values.
This has been a busy and successful year with a wider number of GPs referring to
our services and an increased number of patients choosing to access our hospital.
Our mission remains, to be expert in delivering elective day case services to patients
in our local community and beyond, delivering services we would be happy to
receive ourselves. We have had our commitment to quality recognised this year in a
number of key achievements:
 The number of patients who have taken time to enter reviews on NHS choices
and it is particularly pleasing to see that the hospital has an overall 5 star
rating
 In addition, all of our patient feedback mechanisms show consistently high
satisfaction
 We meet all CQC standards, an unannounced inspection took place in
November and resulted in a very positive report with no conditions
 Only 2 complaints received in the last 12 months
 Obtaining Joint Advisory Group (JAG) accreditation for endoscopy services
Despite these accolades we are not complacent and our priorities for 2014/15 are
focused upon ensuring continuous improvement, creating services centred around
the patient, getting it right first time and putting patient safety at the heart of
everything we do.
Donna Thornton
General Manager, Cobalt Hospital
Quality Accounts 2013/14
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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.
Donna Thornton, General Manager
Cobalt Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Peter Hodgkinson, Medical Advisory Group Chair:
Alex Clason, Clinical Governance Committee Chair:
Stefan Andrejczuk, Regional Director:
Who comment that it is gratifying to confirm the high level of service provided by
Cobalt Hospital which remains a front runner in the delivery of care in Ramsay
Healthcare UK with its continued commitment to improvement and quality of patient
care.
Quality Accounts 2013/14
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1.2.1 Cobalt Hospital
Cobalt Hospital, formerly Cobalt Treatment Centre, was built in 2005 and is a
modern, purpose-built unit designed for the diagnosis, assessment and treatment of
conditions on a day case basis for adults aged 18 years and over. The Hospital is a
single level building comprising of a modern and airy reception area, an outpatient
unit with a suite of consulting rooms and a surgical unit housing two theatres and
dedicated recovery areas. Located within the Cobalt Business Park there is ample
free car parking, good public transport links and easy access to main road networks.
Cobalt Hospital currently provides NHS services for the following specialties: GI
endoscopy, general surgery, orthopaedics and plastic surgery. Patients who self pay
or have private medical insurance are seen under our Premium Care scheme for the
following specialties: cosmetic surgery, GI endoscopy, general surgery, orthopaedics
and plastic surgery.
North of Tyne Clinical Commissioning Group were our lead commissioner of NHS
Services for 2013/14, on behalf of neighbouring clinical commissioning groups, with
regular service review meetings held to discuss performance. Patients were referred
and travelled from Northumberland, North Tyneside, Newcastle, Sunderland, South
Tyneside and Gateshead.
Referral to the hospital for NHS services is direct from GP via Choose and Book and
we have dedicated Choose and Book Co-ordinators and a GP Liaison team to
facilitate the referral process. We hold regular Choose and Book workshops at the
hospital inviting medical secretaries from local GP practices. These events give an
opportunity to tour the facilities and experience the ‘patient pathway’ first hand.
This year saw over 4,500 patient procedures at Cobalt Hospital with a breakdown of
work being 97% NHS patients and 3% private patients. In terms of workforce there
are 36 members of staff employed at Cobalt Hospital, a mix of full time and part time,
of which 51% are clinical posts and 49% support staff.
Quality Accounts 2013/14
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Part 2
2.1 Priorities for Improvement 2013/2014
On an annual cycle, Cobalt 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 A review of clinical priorities for 2014/15 (looking back)
Surgical safety checklist - There have been no ‘Never Events’ at Cobalt Hospital in
the period and audit of compliance maintains a key focus with monthly audit of WHO
safety checklists as part of CQUIN indicators undertaken by the Ambulatory Care
Team Leader. Scores have ranged from 92% to 100% compliance and action plans
are devised where there is evidence of noncompliance. The key area that causes
noncompliance is at the sign out stage which will remain a focus in 2014.
VTE assessment – There has been improvement in compliance with completion of
VTE documentation for patients where appropriate. Support from the Group Medical
Director included a presentation to the Medical Advisory Committee on clinician
responsibilities in the completion of VTE risk assessments. Quarterly audit scores
have demonstrated improvement and compliance remain a focus across the whole
of the Ramsay Group.
Infection Control – We have had no reportable infections and no outbreaks
reported in the period. We continue to screen patients for MRSA where appropriate
in line with DOH guidelines and training for staff on hand hygiene is mandatory. The
infection control team have worked to improve standards in environmental cleaning
in the period with the Clinical Lead leading quarterly environmental audits in the
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period. Improvements in completion of clinical equipment cleaning schedules have
been noted following review of cleaning matrix and clarity of responsibilities. Low
scores were in relation to none completion of cleaning schedules. Audit scores have
improved from 84% in February 2013 to 92% in February 2014 and a CQUIN target
has been set this year to further improve compliance.
PLACE (Patient lead assessment of the care environment) – The first PLACE
assessment was carried out in June 2013, two patient representatives performed the
assessment with two members of Cobalt Hospital staff including the General
Manager and the Infection Control Link Nurse. The patients were both very
impressed with the facilities and gave very positive feedback on the day.
Incident reporting – The Ramsay Group risk management system Riskman is used
to report clinical incidents, health and safety incidents, compliments and complaints.
Additional training has been given to all staff to ensure timely and effective reporting
and compliance in reporting has been good. There have been no serious untoward
incidents reported in the period.
Competency training – Competency assessment tools have been completed for all
staff clinical staff appropriate to their area of practice.
Preoperative assessment – The preoperative assessment policy is followed and
provides safe and efficient assessment of all patients following their outpatient clinic
appointment. Patients complete a medical questionnaire which is reviewed by the
nursing staff to determine the level of preoperative assessment required. We have
modelled the patient pathway to include early patient assessment expanding
boundaries and demonstrating excellence in practice. Our low conversion to
inpatient demonstrated by our transfer rate of 1 per 1000 admissions is testament to
good patient assessment and planning, setting patient expectation, anaesthetic
techniques and staff expertise.
Meeting Endoscopy Standards – Cobalt Hospital was successful in achieving JAG
accreditation in September 2013 following a comprehensive assessment. This is a
huge achievement for the hospital endorsing the excellent endoscopy service
provided to the local community.
Patient satisfaction survey – The web based satisfaction survey has been in place
since February 2013 and response rates have gradually increased over the period
with a response rate of 53.8% at the end of March 2104. The overall satisfaction rate
for the year was 97%. We have gained a five staff rating on NHS choices following
very positive patient feedback posts describing positive patient experience. We are
proud to report that we received only two formal complaints in the period which is a
huge achievement and a result we are extremely proud of. We introduced a patient
focus group at the end of 2013 involving our staff in reviewing the many forms of
patient feedback we receive and encouraging autonomy in making recommendations
for practice.
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Patient reported outcome measures studies (PROMS) – Participation rates for
patients undergoing inguinal hernia repair remain low and has been a CQUIN target
in the period. Return rates have gradually improved with the surgeon actively inviting
the patients to complete the questionnaire prior to their surgery and nursing staff are
supporting this process. Previous processes involving completion at preoperative
assessment yielded poor completion rates. This continues to be a focus.
Information Security – Cobalt Hospital achieved the information security
accreditation ISO 27001. The process of raising the importance of data protection
and information security has been successful and fully embraced by our staff.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
Patient Safety
Surgical Safety Checklist - Never Events’ are serious, largely preventable patient
safety incidents that should not occur if the available preventative measures have
been implemented as standard practice. Monthly audits will continue to be
undertaken with an expectation of 100% compliance, where this is not achieved
actions plans will be developed and responsibilities communicated with the teams.
Briefing and debriefing sessions for all day case procedures continue and give
opportunity for shared learning, recommendations for future practice and aim to
encourage autonomy for all members of the team. Compliance will be monitored by
regular audit and reviewed by Clinical Governance and Medical Advisory Committee.
VTE assessment - a VTE risk assessment is completed for patients according to
CM 001 VTE policy and requires consultants to review and to complete prior to
procedure. This remains a focus at Cobalt Hospital with quarterly audit completed to
maintain standards. Results are reviewed and actions determined at both Clinical
Governance and Medical Advisory Committees.
Staffing – To ensure adequate numbers of skilled staff are available to care for our
patients staff rosters are prepared in advance. An electronic rostering tool ‘Allocate’
was introduced in December 2013 taking into account the necessary skill mix for the
days patient activity. We monitor staff satisfaction with a biannual survey; results for
2013 show a satisfaction score of 4.6 which maintains our position on previous
years. The Ramsay Academy provides learning and development opportunities for
all staff and the Management Development Framework provides opportunities for our
leaders to develop skills and knowledge. We recognize the value of the Health Care
Assistant (HCA) within Ramsay and competency assessments are in place to allow
all HCA’s to reach their full potential. Acknowledging the Cavendish review we are
adopting the ‘productive team’ model ensuring ‘an holistic approach to care, focused
on ensuring the best possible outcomes for the patient, staff and the organization’.
We promote a culture of support and mentoring in developing our existing staff and
will be introducing apprenticeships across different job roles in the next year.
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Clinical effectiveness
Maintaining Endoscopy Standards – Following successful JAG (Joint Advisory
Group on Gastrointestinal Endoscopy) accreditation in 2013 biannual submission to
GRS (Global Rating Score) continues, this tool enables us to assess how well we
provide a patient-centered service. Demonstrating compliance against the four
domains:




clinical quality
quality of patient experience
workforce
training
At our last GRS audit we demonstrated level A in all domains and we will continue to
review and audit against the GRS standards to maintain this level of compliance.
Patient experience – informing patient choice
Patient satisfaction survey – We will continue to encourage patients to provide
feedback using our web based satisfaction survey. ‘Hot alerts’ received following
completion of the survey will be reviewed by the General Manger and Clinical Lead
and action taken where there are areas identified for improvement. All comments
positive and negative are shared with the whole team along with a monthly patient
satisfaction dashboard. Compliments and complaints are reviewed at Clinical
Governance and Medical Advisory Committees and lessons learned shared with the
teams. We will continue to monitor posts on NHS choices and commit to retaining
our five star recommendations. Our patient focus group will be further developed in
the year to include consultant and patient representation to ensure a robust
approach to patient feedback; we aim to maintain a satisfaction score of 97%.
Friends and Family Test - The friends and family test is being rolled out to include
day case and outpatients from April 2014. This is a national CQUIN indicator this
year with a target for early implementation of F&F in outpatients and day case
departments by 31st October 2014. Patients will be invited to complete a paper
questionnaire or electronic questionnaire following their visit to the hospital. Results
from this survey will be reviewed by the patient focus group and shared with the
whole team.
Patient reported outcome measures studies (PROMS) – This is a national
indicator providing important information regarding the effectiveness of hernia
surgery as perceived by the patient. We will continue to monitor patient response
rates as part of a local CQUIN indicator with a graduated quarterly target to achieve
75% compliance by quarter four. The consultant surgeon will ensure patients are
fully informed and invited to take part in the survey by completing a questionnaire
prior to their surgery.
Quality Accounts 2013/14
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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 2013/14 Cobalt Hospital provided NHS services across four specialties.
Cobalt 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 2013 to 31st March
14 represents 100 per cent of the total income generated from the provision of NHS
services by Cobalt Hospital for 1 April 2013 to 31st March 14
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard are
reviewed each year. The scorecard is reviewed each quarter by the hospitals senior
managers together with Regional and Corporate Senior Managers and Directors.
The balanced scorecard approach has been an extremely successful tool in helping
us benchmark against other hospitals and identifying key areas for improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient safety
and quality were:
Human Resource
Staff Cost % Net Revenue
10.4%
HCA Hours as % of Total Nursing
24.4%
Agency Cost as % of Total Staff Cost
1.4%
Admitted Care Hours Worked PPD
3.6
Staff Turnover
10.5%
Sickness
3.07%
Lost Time
17.8%
Appraisal %
100%
Mandatory Training %
100%
Staff Satisfaction Score
4.46
Number of Significant Staff Injuries
0
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Patient
Formal Complaints in year
2
Patient Satisfaction Score
97%
Significant Clinical Events
0
Readmission per 1000 Admissions – less than 1 per 1000
Quality
Workplace Health & Safety Score
94%
2.2.2 Participation in clinical audit
The national clinical audits and national confidential enquiries that Cobalt Hospital
participated in, and for which data collection was completed during 1 April 2013 to
31st March 2014, 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)
% cases
submitted
Small volumes
The reports of the national clinical audit from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Cobalt Hospital is working to
improve participation rates for preoperative surveys for inguinal hernia repair by
consultant engagement with patients preoperatively.
Local Audits
The reports of over 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Cobalt Hospital ensures action
plans are written with clear time frames for improvement and responsibilities
assigned.
Over all good compliance is demonstrated and action plans are completed to ensure
improvements are made. Our focus for 2014/15 is to further improve record keeping
Quality Accounts 2013/14
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in relation to VTE compliance and compliance with management of the deteriorating
patient.
The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 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 Cobalt Hospitals income from 1 April 2013 to 31st March 2014 was
conditional on achieving quality improvement and innovation goals agreed. Cobalt
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.
2.2.5 Statements from the Care Quality Commission (CQC)
Cobalt Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions. On the most
recent CQC inspection 11th November 2013 Cobalt Hospital was inspected on
outcomes 1, 4, 8, 12 and 21 and full compliance was awarded.
Cobalt Hospital has not participated in any special reviews or investigations by the
CQC during the reporting period.
2.2.6 Statement on Data Quality
Cobalt Hospital works hard to ensure accurate data quality is at the heart of
everything we do, evidenced by excellent SUS submission rates.
Where applicable, using findings from the internal audit programme, the hospital
works to develop data capture and validation methods, ensuring continuous
improvement in quality standards.
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NHS Number and General Medical Practice Code Validity
Cobalt Hospital submitted records during 2013/14 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; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code:



100% for admitted patient care;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall
score for 2013/14 was 83% and was graded ‘green’ (satisfactory).
Clinical Coding error rate
Cobalt Hospital was not subject to the Payment by Results clinical coding audit
during 2013/14 by the Audit Commission.
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2.2.7 Stakeholders views on 2013/14 Quality Account
Statement from North Tyneside CCG on behalf of Newcastle Gateshead CCG
Alliance and Northumberland CCG regarding the Quality Accounts dated
2013/14 for Ramsay Health Care UK:
“NHS North Tyneside CCG as the lead commissioner for services at Cobalt Hospital
welcomes the opportunity to provide this statement for their Quality Accounts
2013/2014. The Quality Account has been has been reviewed in accordance with
the Department of Health Guidance and Monitor requirements. This statement has
been developed in consultation with neighbouring CCGs. Over the past year NTCCG
has developed constructive relationships with Cobalt Hospital, reviewing
performance at regular Quality Review Group meetings. The Quality Account
2013/2014 is detailed, clear and comprehensive and provides a balanced view of
achievement. It reflects the significant increase in activity over the past 12 months,
of which 97% were patients referred directly from the NHS.
We acknowledge the achievements of Cobalt Hospital in a number of key areas
during 2013/2014 such as VTE assessment and the surgical safety checklist, but
would particularly like to offer our congratulations on the achievement of Joint
Advisory Group on Gastrointestinal Endoscopy accreditation for endoscopy services
in September 2013. We also commend the approach to improving patient
experience which continues to be a priority in 2014/2015.
Whilst the CCG is satisfied that the key areas outlined for 2014/2015 are appropriate
the CCG would like to see an increase in staff satisfaction from the 4.6 which has
been reported over two successive years. Added to this, an improvement in the
privacy, dignity and wellbeing element of the Patient-Led Assessments of the Care
Environment (PLACE) which was 78.49% in 2013/2014 should be prioritised for
improvement in 2014/2015. The CCG would also like to see further evidence of how
patients have been involved in shaping Cobalt Hospital throughout 2013/2014.
Overall, this Quality Account is a balanced and accurate view of achievements and
outlines how Cobalt Hospital has been working to improve the quality of care it
delivers. We will continue to work in partnership to ensure delivery of 2014/2015
quality targets which include an incremental rise in patient reported outcome
measures (PROMS) and implementation of Friends and Family Test reporting.”
Statement from Healthwatch North Tyneside:
“The Board notes the generally good performance of your hospital particularly the
high patient satisfaction rates at 97%. However, the Board was concerned that the
score for “Dignity, Privacy and Wellbeing” on page 27 is only 78.49%. We note that
you have an action plan in place to address this and would be grateful if you could
keep us informed of progress on this issue. We look forward to a future progress
update.”
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Part 3: Review of Quality Performance
“This publication marks the fifth 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.”
Jane Cameron, Director of Safety and Clinical Performance
Ramsay Health Care UK
Ramsay 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
Quality Accounts 2013/14
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(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 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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3.1 The Core Quality Account indicators
National Mortality Rates:
Period
Best
Worst
Average
2012/13
RKE
0.65
RXL
1.17
Eng
1
2013/14
RKE
0.63
RBT
1.15
Eng
1
Cobalt Hospital:
Period
Cobalt
2012/13
NVC29
0
2013/14
NVC29
0
Cobalt Hospital considers that this data is as described, we have had no reported
deaths.
National Expected Deaths:
Period
Apr12 Mar13
Jul12 - Jun13
Best
Worst
Average
RBA
0.1
RWH
44.0
Eng
20.4
RBA
0.0
RWH
44.1
Eng
20.2
Cobalt Hospital:
Period
Cobalt
2012/13
NVC29
0.0
2013/14
NVC29
0.0
Cobalt Hospital considers that this data is as described as we do not admit patients
for palliative care.
National PROMs: Hernia repair
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT415
0.157
NVC27
0.015
Eng
0.085
RTG
0.138
RNA
0.019
Eng
0.086
Cobalt Hospital
Quality Accounts 2013/14
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Period
Apr12 Mar13
Apr13 Sep13
Cobalt
NVC29
*
NVC29
*
Cobalt Hospital considers that this data is as described as we have low volumes of
patients admitted for inguinal hernia repair.
Cobalt Hospital has taken action to improve the returns rate of PROMs
questionnaires and so the quality of its services, by actively involving consultants in
the PROMs process in encouraging patient participation.
National PROMs Varicose veins
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
RV8
5.14
NT350
-15.92
Eng
-8.374
RTD
-9.74
RLN
-10.52
Eng
-9.46
Cobalt Hospital
Period
Apr12 Mar13
Apr13 Sep13
Cobalt
NVC29
*
NVC29
*
Cobalt Hospital considers that this data is as described as we have low volumes of
patients admitted for varicose vein surgery, as the policy around procedures of
limited value are followed.
National Readmissions
Period
Best
Worst
Average
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
Cobalt Hospital
Period
Cobalt
2012/13
NVC29
0
2013/14
NVC29
0
Quality Accounts 2013/14
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Cobalt Hospital considers that this data is as described as we have a low level of
readmissions reported.
National VTE assessment
Period
Best
Worst
Average
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
Cobalt Hospital
Period
Cobalt
13/14 Q3
NVC29
98.8%
13/14 Q4
NVC29
100.0%
Cobalt Hospital considers that this data is as described, we monitor compliance
monthly and agree an action plan if completion rates drop below 95% maintaining a
target above the national average.
Cobalt Hospital will continue to audit to maintain the quality of its services.
National C Difficile rate
Period
Best
Worst
Average
2012/13
Several
0
RNA
58.2
Eng
22.2
2013/14
Several
0
RVW
30.8
Eng
17.3
Cobalt Hospital
Period
Cobalt
2012/13
NVC29
0.0
2013/14
NVC29
0.0
Cobalt Hospital considers that this data is as described as there have been no
reported cases of C Difficile. Cobalt Hospital intends to maintain this rate by ensuring
robust infection control measures are in place.
National Patient Safety
Period
Best
Worst
Average
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
Cobalt Hospital
Period
Cobalt
2012/13
NVC29
0.57
2013/14
NVC29
2.76
Cobalt Hospital considers that this data is as described, we have a low level of
patient incidents reported. Cobalt Hospital ensures a safe environment is maintained
with all staff undertaking training and competency assessments and a robust audit
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system. All incidents and accidents are reviewed at clinical governance, health and
safety and medical advisory committee and action plans developed and lessons
learned shared.
National SUI’s Severity level 1
Period
Best
Worst
Average
Jul - Sep 12
NA
NA
NA
Oct11 - Sep12
NA
NA
Eng
11,563
Cobalt
Period
Cobalt
2012/13
NVC29
0.0%
2013/14
NVC29
0.0%
Cobalt Hospital considers that this data is as described, there have been no level 1
severity incidents reported. Cobalt Hospital intends to maintain this rate by ensuring
an effective clinical governance framework.
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.
3.2.1 Infection prevention and control
Cobalt Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 5 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.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a corporate level Infection Prevention and Control
(IPC) Committee and group policy is revised and re-deployed every two years. Our
IPC programmes are designed to bring about improvements in performance and in
practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
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Programmes and activities within our hospital include:
The infection control link nurse has provided training in hand hygiene to all staff and
completes a hand hygiene training session during the staff induction day for all new
staff.
The consultant microbiologist presented a teaching session to the clinical staff
entitled ‘Myth busting’ covering universal precaution guidance in clinical practice
which was very well received.
In May a hand hygiene awareness day was lead by the infection control link nurse
and this involved staff, patients and visitors visiting an information stand in the
waiting area. Demonstrations were given and patients and staff were given individual
hand hygiene gel dispensers for their own use.
Observational hand hygiene audits were undertaken by the Consultant Microbiologist
and Infection Control Link Nurse resulting in additional gel dispensers being placed
in the unit. A poster campaign targeting staff to ‘gel in and gel out’ was successful in
increasing patient satisfaction scores in questions relating to staff hand hygiene.
Our infection control rate at Cobalt Hospital remains very low and our reporting and
investigating of potential infections has improved in the last year. Any patient
presenting signs of an infection is reviewed by the infection control link nurse and a
root cause analysis completed to determine any possible trends, results are
presented at our quarterly infection control committee meetings. There have not
been any trends identified in the period.
Infection Rates
Infection Rates
(percentage of Admissiosns)
0.12
0.1
0.08
0.06
0.04
0.02
0
2011/12
2012/13
2013/14
Cobalt Hospital
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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 Cobalt Hospital, providing us with a
patient’s eye view of the buildings and facilities, 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.
2013 PLACE results:
Cleanliness - 95.80%
Condition, Appearance and Maintenance - 90.38%
Privacy, Dignity and Wellbeing - 78.49%
An action plan was compiled, as a day case facility patients do not have access to
TV radio or internet this reflected a low score for privacy and dignity. Some evidence
of high level dust was noted and immediately actioned. An active maintenance
programme was introduced to ensure the condition and maintenance of the facilities
is maintained to a high standard.
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager which
ensures we keep up to date with all safety issues.
In addition to mandatory training the Health and Safety Coordinator has coordinated
sharps awareness programmes throughout the year ensuring the use of sharps safe
devices where these are available. There has also been training on waste
management ensuring the correct segregation of waste taking into account the effect
on the environment and raising staff awareness on this issue. We have supported a
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team member to complete a training course to enable them to provide manual
handling training to all of our staff.
3.3 Clinical effectiveness
Cobalt hospital has a Clinical Governance team and committee that meet regularly
through the year to monitor quality and effectiveness of care. Clinical incidents,
patient and staff feedback are systematically reviewed to determine any trend that
requires further analysis or investigation. More importantly, recommendations for
action and improvement are presented to hospital management and medical
advisory committees to ensure results are visible and tied into actions required by
the organisation as a whole.
3.3.1 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.
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.3
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Cobalt Hospital
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Cobalt Hospital continues to have a very low return to theatre rate as a percentage
of overall admissions. There were no trends identified and the increase seen from
2012/13 is still below the national average.
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
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
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
3.4.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of
the hospital so we receive a true reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked are
used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Quality Accounts 2013/14
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Manager within 48hrs of receiving them so that a response can be made to the
patient as soon as possible.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
99.1
97.0
2012/13
2013/14
20
0
Cobalt Hospital
We have consistently maintained an overall satisfaction rate above 95% and
proactively seek patient feedback to ensure we maintain high patient satisfaction
rates. A change of satisfaction survey in early 2013 means the data is not
comparable.
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3.5 Cobalt Hospital Case Study
During 2013 Cobalt Hospital worked towards achieving JAG accreditation. As part of
this project an Endoscopy Users Group was developed which included
representation from Consultant Gastroenterologists, Endoscopy Lead, Matron,
administration and clinical staff.
To ensure patients were represented in the user group the Endoscopy Lead and the
rest of the endoscopy team actively sought patient representation and following an
episode of care a patient agreed to participate in the endoscopy user group. The
patient was subsequently invited to attend the endoscopy user group held in August
2013.
The patient representative reviewed the results of the annual endoscopy patient
survey with the endoscopy team and was very impressed with the results saying
they reflected her own experience. Two areas were debated: offering a choice of
morning or afternoon appointments had been raised in the survey results and the
user group committed to review schedules and gastroenterologist availability to
ensure choice across the week was offered. Secondly the availability of a private
room for patients to have their care discussed with the gastroenterologist was
discussed. Whilst the patient representative felt that the individual pods pre and post
procedure afforded sufficient privacy a dedicated discharge room was subsequently
created as well as access to a private room for the breaking of bad news.
The endoscopy team found the contribution of the patient representative invaluable.
In working towards successfully achieving Jag accreditation patient feedback played
a key part in the preparation. The Jag assessors commended the endoscopy team
on their preparation and excellent endoscopy service provided; they were particularly
impressed with the team for inviting a patient representative to join the endoscopy
user group.
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Appendix 1
Services covered by the Quality Account
Speciality
General Surgery
GI Endoscopy
Orthopaedic Surgery
Plastic Surgery
Service
Minor Skin
Varicose Veins
Hernia Repair
Rectal Surgery
Colonoscopy
Flexible Sigmoidoscopy
Gastroscopy
Hand
Knee
Shoulder
Wrist
BCC
Skin lesions/cysts
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Appendix 2 - Clinical Audit Programme 2013/14 (each arrow links to the audit to be completed in each month)
Quality Accounts 2013/14
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Cobalt 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:
Cobalt Hospital
Silverlink North
Cobalt Business Park
North Tyneside
NE27 0BY
Tel: 0191 2703 250
Email: [email protected]
www.cobalthospital.co.ukCentres
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Quality Accounts 2013/14
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