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New Hall Hospital

Quality Account 2013/14

No reported MRSA bloodstream infectionsIn the past 5 years

ContentsIntroduction Page

Welcome to Ramsay Health Care UK

Introduction to our Quality Account

PART 1 – STATEMENT ON QUALITY

1.1 Statement from the General Manager

1.2 Hospital accountability statement

PART 2

2.1 Priorities for Improvement

2.1.1 Review of clinical priorities 2013/14 (looking back)

2.1.2 Clinical Priorities for 2014/15 (looking forward)

2.2 Mandatory statements relating to the quality of NHS services provided

2.2.1 Review of Services

2.2.2 Participation in Clinical Audit

2.2.3 Participation in Research

2.2.4 Goals agreed with Commissioners

2.2.5 Statement from the Care Quality Commission

2.2.6 Statement on Data Quality

2.2.7 Stakeholders views on 2013/14 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account indicators3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

3.5 Case Study

Appendix 1 – Services Covered by this Quality AccountAppendix 2 – Clinical Audits

Welcome to Ramsay Health Care UK

New Hall Hospital is part of the Ramsay Health Care GroupThe 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 of 43

Introduction to our Quality Account

This Quality Account is 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.


Part 11.1 Statement on quality from the General ManagerWelcome to New Hall Hospital’s quality account. This report outlines the Hospitals approach to quality improvement, progress made in 2013-14 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 Health Protection agency’s Surgical Site Surveillance Service and Patient Reported Outcome Measures for Hip and Knee replacement, hernias and cataracts.

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 taken part in the QE research Inpatient survey and received excellent feedback. We have also participated in the patient and staff NHS Friends and Family Survey, and have been delighted with the many positive comments we have received.

In 2013-2014 we underwent significant refurbishment of all en suite rooms, reception and premium care lounge. We also developed and implemented the Surgical Admissions unit to further improve the quality of service we offer.

Fiona Taylor

General Manager

New Hall Hospital


1.2 Hospital Accountability StatementTo 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

This report has been reviewed by:

MAC Chair-Mr David Chapple

Clinical Governance Committee Chair-Mr Peter Guy

Regional Director Stefan Andrejczuk

Commissioner/PCT and other external bodies

Wiltshire CCG

Dorset CCG-Sally Shead Director of Quality

Hampshire CCG-Andrea O Connell Director of Quality


Welcome to New Hall HospitalNew Hall Hospital

New Hall Hospital 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 43 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 or 16 if private), whether medically insured, self-pay, or from the NHS).

We deliver a full range of specialist surgical and medical services (excluding cardiac and neurosurgery) to include orthopaedics, spinal, ENT, gynaecology, urology, colorectal, breast and cosmetic surgery and general medicine.

Patients requiring level 2 critical care are treated and cared for by appropriately trained staff in a dedicated high dependency unit.All Ramsay Health Care UK hospitals have transfer arrangements in place with their local trust or critical care network for level 3 care.

In 2013/14 we treated a total of 5856 patients. 4131 NHS patients (70%) and 1725 private patients (30%).

We currently employ

Consultants (directly employed by Ramsay) 3

Consultants (with practicing privileges) 100 (all specialities)

Registered Nurses 40 + 8 bank

Operating Department Practitioners 10 + 3 bank

Radiographers 4 + 5 bank

Physiotherapists 5 + 4 bank

Health Care Assistants 19


Other Support Staff 21 + 4 bank

Administrative staff 46 + 8 bank

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

We provide an outreach service for outpatient NHS patients at Poole Hospitals and Blandford clinic for spinal and orthopaedic services.

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 Learns” 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, Dorset and Somerset) to provide a range of surgical services within the standard acute contract.

We work closely with the Salisbury District Hospital who provide us with blood transfusion, urgent pathology, histopathology and access to level 3 critical care services.


Part 2

2.1 Quality priorities for 2013/2014

Plan for 2013/14

On an annual cycle New Hall 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 2013/14 (looking back)

1. World Health Organisation (WHO) Surgical safety checklist – completion of the checklist is a key safety element for patients undergoing surgical procedures at New Hall. Accurate completion of the WHO checklist is audited regularly and the results are consistently over 90% compliance.


2. Bar coding for patient identity bands – this priority has been on hold awaiting a formal notice for implementation. However, this is still on Ramsay’s agenda and will be introduced as it is still considered best practice and will prepare us for many patient care initiatives which will require patients to have a barcode on their wristbands.

3. Venous Thromboembolism (VTE) risk assessment and PreventionNew Hall hospital has established a robust policy to comply with Ramsay policy in order to reduce avoidable death, disability and chronic ill health from VTE. We have reduced the variance of prophylactic measures used at New Hall hospital in order to minimise human error and allow outcomes to be measured. The hospital has an excellent VTE risk assessment compliance record. Data submitted to UNIFY shows 99.8% achievement from April 13th to March 14.

4. Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.Preventative measures have been implemented and there have not been any “Never event” incidents in this reporting year at New Hall hospital

5. Real time incident reporting – All incidents, complaints and clinical key performance indicators such as readmissions, reoperations, healthcare acquired infections etc. are entered onto the corporate risk management system (RISKMAN) in real time so trends can be analysed and identified promptly. This enables us to review events as they happen and prevent recurrence thus contributing to patient safety.

6. JAG Accreditation-We were delighted to pass our JAG accreditation assessment first time on 3rd July 2014. This will allow us to further enhance our endoscopy service and provide reassurance to commissioning bodies that we meet all the criteria to run a safe, efficient and effective service.

7. Cleanliness and infection prevention - There have been no MRSA bacteraemias or C Difficle at the hospital over this reporting period. We screen all patients for MRSA prior to admission to New Hall and all staff have a mandatory requirement to undertake hand hygiene training. We maintain our regular audit programme which includes hand hygiene, urinary catheter and intravenous line care, and our cleaning standards and physical environment. We participate in the Health Protection Agency data collection for surgical site infections following hip and knee joint replacements and we have not had cause to report any infections to the HPA during the last year.


8. National Joint Registry (NJR) The purpose of the NJR is to define, improve and maintain a quality of care of individuals receiving hip, knee and ankle joint replacements across the NHS and independent healthcare sector. Shoulder and elbow replacements have also been added to the list in addition to those above. New Hall registers all patients undergoing this type of surgery with the NJR providing they consent to this. The NHS number tracing rate is to ensure that patients can be traced easily and information from different providers can be collated. All staff that input the data have been informed how to ensure NHS number tracing can be achieved to achieve a 100% traceability rate. We have maintained consistently good scores for data submission to the NJR.

9. Clinical training – New Hall hospital will continue to ensure that patients are cared for by safe and competent staff. Providing quality care for patients is a high priority at New Hall Hospital and all relevant clinical staff will be supported through training and protected time to achieve competency level education. Blood transfusion competencies – in line with patient safety we will ensure that blood transfusions or blood products are only handled/administered by competent trained staff. New Hall hospital has achieved good levels of compliance with mandatory training/e-learning.

10.Safeguarding- New Hall hospital takes its responsibility for safeguarding vulnerable members of society seriously. We provide in house training and easy to use flowcharts for help and advice. These are available in all areas. All staff working within the hospital are required to have an enhanced CRB check and have undergone mandatory training in safeguarding. Relevant staffs have also undergone training in the Mental Capacity Act and Deprivation of Liberty although neither have had to be used in this reporting period. The PREVENT programme to identify and support vulnerable individuals who may be at risk of radicalisation is mandatory and is currently underway for all members of staff to attend. Equality, diversity and human rights are a theme running through Ramsay Health Care. The organisations integrated governance framework, Group policies and practice comply with current legislation. To date there have not been any safeguarding incidents to report at New Hall Hospital.

11. Information Security-New Hall Hospital was re audited in March 2013 and achieved Information Security accreditation ISO270001.

12.Staffing- Ramsay invested in an electronic rostering system in 2013 (Allocate) Departmental Managers are required to put key staffing requirements into the system which then generates an auto roster in line with staffing key performance indicators and local staffing requirements.


This has the added advantage of recording training hours and reminds staff of key training requirements and professional registrations.

Clinical effectiveness

Surgical Admissions Unit – better outcomes and improving patient experience

In December 2013 we opened our Surgical Admissions Unit. This was in order to provide our patients with a more efficient patient pathway through the hospital. All patients are admitted via the Surgical Admissions unit which is adjacent to theatre. This close proximity to theatre has allowed us to implement staggered admissions so patients aren’t waiting for significant amounts of time pre operatively. Patients who are undergoing day case procedures appreciate the efficient of the system which means they only have to spend a short period of time in hospital. We are the first hospital within the Ramsay group to develop a Surgical Admissions unit and proud that it has provided a much more efficient t service for our patients

Electronic patient information

All patients are sent a substantial amount of paperwork prior to admission and concerns were raised that information was getting lost and not received. We implemented the process of putting all the patient information on line and setting up a secure email by which the patient could receive all communication. This is not only easier for the patient but also ensures an audit trail as to when and where documents were sent.

Group pre assessment

New Hall pre-assessment and physiotherapy team have implemented a group pre assessment process for all spinal surgery. It was recognised that seeing each patient individually was not always the most efficient way of giving the required pre-operative information to patients and that holding group sessions encouraged discussion and group interaction. The patients are first assessed at time of consultation to ensure they are fit for surgery and then they are invited to attend a group session where they are given a procedure specific presentation by the physiotherapist and/or spinal nurse practitioner and an opportunity to ask questions and meet other patients having the same procedure. The group session is followed up by an individual assessment by the spinal nurse practitioner.

Private Hospitals Information Network

Ramsay Health Care is a member of Private Hospitals Information Network which enables providers to benchmark against other providers for key performance


indicators (activity volumes, mortality, day case rates, return to theatre, readmissions etc.

Improve National benchmarking

it was recognised that we needed more transparency between ourselves and other independent sector providers/the NHS in order to monitor and improve our services. This is even more important now we are working in partnership with the NHS. We will be benchmarking in the following areas;

VTE risk assessment compliance – benchmarking through the national stats website. Link; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH122283

PROMS results – benchmarking through national PROMS website. Link: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID-1295

Patient experience – informing patient choice

Patient Reported Outcomes Studies (PROMs)- We continue to monitor the national PROMs results for Hip, Knee, Varicose Veins and Hernia surgery by offering all patients who undergo this type of surgery the opportunity to complete a questionnaire before and after surgery to monitor an improvement in their quality of life. Encouraging their use in identifies poor outcomes and allows us to review practice where necessary.

We share the results with Surgeons and physiotherapists and encourage them to use them to review their practice by meeting and discussing the results with their teams and benchmarking against other sites.

We are expanding our use of PROMS surveys to cover more procedures to enable better understanding of treatment outcomes from the patients view point. We have also implemented PROMS for spinal surgery using the British Spinal Registry.

Patient satisfaction survey – New Hall has always achieved a high level of patient satisfaction even during the recent refurbishment. During 2013 the paper based survey was replaced by a web based questionnaire/telephone survey which allows feedback to be received more quickly. We receive a weekly “hot alert” comments so we can respond to concerns in a more timely manner.


http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID-1295

http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID-1295

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH122283

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH122283

The latest formal report relates to patients discharged in July 2014 and there was a response rate of 60%. In response to the question, Overall, how would you rate your experience, New Hall scored 97% and 97% of patients said they would recommend the hospital. All patients are given a “we value your opinion” leaflet on discharge and asked to take the friends and family test which is where they say whether they would recommend the hospital to their friends and family. The friends and family test has also recently been rolled out to outpatients.

2.1.2 Clinical Priorities for 2014/15 (looking forward)

Patient Safety

We will increase the number of patients who report they attend primary or secondary care on discharge in relation to their primary procedure at New Hall Hospital. We will monitor this by phoning patients 30 days post discharge. This is a local CQUIN agreed with Wiltshire CCG and will ensure that patients are being discharged appropriately and with comprehensive follow up advice.

Clinical Effectiveness

To reduce the number of avoidable admissions within 30 days of surgery. This will be monitored via NHS clinical indicators which includes readmission to other hospitals.

Patient Experience

Increase the number of patients who receive copies of their Consultant to GP letter. This is so patients can be kept fully informed regarding their care and discharge. This will be monitored via the patient questionnaire.

We will continue to improve the services offered to patients to ensure they receive a positive experience. This will be monitored via the patient questionnaire and the friends and family test and “we value your opinion” leaflet.


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 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 in 1 April 2013 to 31st March 14 represents 76.64 % of the total income generated from the provision of services by New Hall Hospital 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 ResourcesStaff Cost as % Net RevenueHCA Hours as % of Total NursingAgency Cost as % of Total Clinical Staff CostWard Hours PPD% Staff Turnover rolling 12 months% Sickness rolling 12 months% Lost TimeAppraisal %Staff Satisfaction Score (max possible 7)

28.7%22%1.4%4.311.14.4318.9%100%4.89


Number of Significant Staff Injuries 0PatientFormal Complaints per 1000 HPD'sPatient Satisfaction ScoreClinical Events per 1000 AdmissionsReadmission per 1000 Admissions

0.2%96%2.25.1

Workplace Health & Safety ScoreInfection Control Audit Score

99%88%

2.2.2 Participation in clinical audit

During 1 April 2013 to 31st March 2014 New Hall Hospital participated in 100% national clinical audits it was eligible to participate in. The Hospital was not eligible to participate in any of the National Confidential Enquiries

The national clinical audits and national confidential enquiries that New Hall Hospital participated in, and for which data collection was completed during 1st 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 OutcomeReview Programme

% cases submitted

National Joint Registry (NJR) 83%

Elective surgery (National PROMs Programme) 72%

The reports of two national clinical audits from 1 April 2013 to 31st March 11 2014 were reviewed by the Clinical Governance Committee and New Hall Hospital intends to take the following actions to improve the quality of healthcare provided

Continue to improve our systems for submitting data Continue to ensure all patients are encouraged to complete the PROMS

questionnaires and the reasoning behind this.

Local Audits

The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 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 can be found in Appendix 2.

The audit results at New Hall show a consistently good level of completion with appropriate action plans and outcomes. We will continue to further improve our standards of record keeping and infection control practices.

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 New Hall Hospital income in from 1 April 2013 to 31st March 2014 was conditional on achieving quality improvement and innovation goals agreed with Wiltshire CCG, Dorset CCG and Hampshire CCG 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.

Agreed goals for 14/15Dorset CQUINS

National CQUINS

1a-F&F-implementation of staff F &FT

1b-F&F Early implementation of F&F in OPD/Physio/Radiology

2-F&F-Increased or maintained response rate

3-F&F-Decreasing –ive 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


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 CQUINS

National CQUINS



2.1b- NHS safety thermometer-Reduction in Prevalence of pressure ulcers

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 CQUINS

1a-F&F-implementation of staff F &FT



3-F&F-Decreasing –ive 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

Local CQUINS

Continuity of care


Reducing face to face follow up

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 2013/14

New Hall hospital has not participated in any special reviews or investigations by the CQC during the reporting period.


2.2.6 Data Quality

We regularly use statistical data to monitor clinical services-we are constantly reviewing this information by quality control initiatives.

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.

NHS Number and General Medical Practice Code Validity

New Hall Hospital submitted records during 2013/14 to the SecondaryUses 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 out patient 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 overallscore for 2013/14 was 83% and was graded ‘green’ (satisfactory).

Clinical coding error rate

New Hall Hospital was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission.


2.2.7 Stakeholders views on 2013/14 Quality Account

West Hampshire CCG are pleased to be able to comment on Ramsay Health Care New Hall Hospital’s Quality Report for 2013/14. The CCG is satisfied with the overall content.

West Hampshire CCG would like to congratulate New Hall Hospital on the achievement of a number of quality outcomes detailed in its 2013/14 Quality Report including:

Excellent record of Venous Thromboembolism (VTE) risk assessment Zero cases of MRSA bacteraemia and Clostridium difficile Implementation of a process that enables patients to securely access patient information

about their procedures to reduce the risk of information being mislaid

The positive results from the patient satisfaction surveys are encouraging, with an average of 96% of patients stating they would be likely to recommend New Hall hospital to friends and family if they needed similar care or treatment during April 2013 – March 2014. It is pleasing to note that New Hall Hospital have a number of methods for obtaining patient experience information and for gaining the patient perspective and that they have agreed to undertake the West Hampshire CCG local Patient Experience Commissioning for Quality and Innovation (CQUIN) scheme during 2014/15. It is noted that New Hall Hospital are now rolling out the Friends and Family Test to outpatients.

The CCG notes that the 2013/14 Patient Led Assessments of the Care Environment (PLACE) results demonstrated that New Hall Hospital was slightly below the National and Ramsay Health Care average for ‘cleanliness’, ‘privacy, dignity and well-being’ and ‘condition and appearance’. However the CCG were aware of the refurbishment that was being undertaken at the time and were assured that the Hospital had actions plans in place to respond to the audit findings. The 2014/15 results demonstrate internal improvement in ‘cleanliness’, ‘condition, appearance and maintenance’.

The Care Quality Commission carried out one routine unannounced visit to the hospital in 2013/14 (8th January 2014) and all standards reviewed were deemed as met.

Overall, West Hampshire CCG are satisfied with the Quality Report for 2013/14. We look forward working closely with New Hall Hospital over the coming year and will review achievement of the 2014/15 quality priorities and indicators through the Clinical Quality Review Meetings in order to further improve the quality of local health services.


Yours sincerely

Andrea O’Connell

Director of Quality (Board Nurse)

Dear Fiona Fiona Taylor New Hall Hospital Salisbury SP5 4EY

Quality Account 2013/14 Thank you for asking NHS Dorset Clinical Commissioning Group (CCG) to review and comment on your Quality Accounts for 2013/14. Please find below the CCG’s statement for insertion into the Quality Accounts. Over the past year New Hall has consistently remained focussed on improving the quality of care provided to individuals who use their services. The key priorities identified for 2013/14 have been successful. With high level of compliance with WHO surgical checklist and the completion of VTE risk assessment, the hospital has exceeded the expected levels. The CCG recognises the effort that is put in to development of new ways of working within the hospital including the revised pre-assessment process and the introduction of surgical admission unit; both systems designed to improve patient experience. During the year the Care Quality Commission conducted an inspection visit to the organisation which found that all areas inspected were compliant. In addition the Hospital has also achieved JAG and Information Security accreditation. The CCG has not been actively engaged in the development of the Quality Improvement Priorities that the Hospital has set for 2014/15 but is in support of these priorities as they align to reduction of re-attendance following admission to hospital and improve the process for sharing information with individuals about their care they have had or will be receiving.


2 Please do not hesitate to contact me if you require any further information. Yours sincerely Sally Shead Director of Quality


Part 3: Review of quality performance 2013/2014

Statements of quality delivery

Deborah Stott MatronReview of quality performance 1st April 2013 - 31st March 2014

Introduction

“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 2014The 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

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.


3.1 The Core Quality Account indicators

Mortality

Period Best Worst Average Period New Hall2012/13 RKE 0.65 RXL 1.17 Eng 1 2012/13 NVC09 0.032013/14 RKE 0.63 RBT 1.15 Eng 1 2013/14 NVC09 0

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 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.

Re-admission

Period Best Worst Average Period New Hall2012/13 RF4 0.0 RYR 15.8 Eng 11.04 2012/13 NVC09 4.72013/14 RF4 0.0 RYR 15.8 Eng 11.08 2013/14 NVC09 7.91


New Hall hospital have a significantly high complexity factor and have an active policy of readmitting patients rather than redirecting them to other sites


Maintain a comprehensive discharge process with appropriate post discharge information and support.

To continue to monitor admissions to other sites


PROMS

Hernia

Period Best Worst Average Period New HallApr12 - Mar13 NT415 0.157 NVC27 0.015 Eng 0.085 Apr12 -

Mar13 NVC09 *

Apr13 - Sep13 RTG 0.138 RNA 0.019 Eng 0.086 Apr13 -

Sep13 NVC09


The number of hernia procedures is too small for New Hall to participate


It will ensure all patients undergoing this procedure are offered the opportunity to undertake this measure and participate if numbers are sufficient

Veins

Period Best Worst Average Period New HallApr12 - Mar13 RV8 5.14 NT350 -15.92 Eng -8.374 Apr12 -

Mar13 NVC09

Apr13 - Sep13 RTD -9.74 RLN -10.52 Eng -9.46 Apr13 -

Sep13 NVC09


The number of vein procedures is too small for New Hall to participate


It will ensure all patients undergoing this procedure are offered the opportunity to undertake this measure and participate if numbers are sufficient

Hips


Period Best Worst Average Period New HallApr12 - Mar13 NT209 24.68 RKE 17.21 Eng 21.32 Apr12 -

Mar13 NVC09 21.746

Apr13 - Sep13 NT318 25.44 RHQ 18.34 Eng 21.61 Apr13 -

Sep13 NVC09


Patients reporting good outcomes when completing their post op questionnaire


To continue to improve return rates

Knees

Period Best Worst Average Period New HallApr12 - Mar13 NT219 20.37 RAP 12.46 Eng 16.01 Apr12 -

Mar13 NVC09 16.111

Apr13 - Sep13 RDE 20.09 RM1 14.32 Eng 16.74 Apr13 -

Sep13 NVC09


Patients reporting good outcomes when completing their post op questionnaire


To continue to improve return rates

Responsiveness to personal care


Period Best Worst Average Period New Hall2012/13 RYR 73.3 RF4 67.4 Eng 75.6 2012/13 NVC09 90.32013/14 RYR 75.9 RJ6 68.0 Eng 76.5 2013/14 NVC09 90.9


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.


To ensure patients’ needs are at the forefront of everything we do.

VTE

Period Best Worst Average Period New Hall13/14 Q3 Several 100% NT244 63.2% Eng 95.8% 13/14 Q3 NVC09 100.0%13/14 Q4 Several 100% NT205 67.0% Eng 96.0% 13/14 Q4 NVC09 100.0%


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.


To ensure patients’ VTE requirements are assessed and patients receive appropriate prophylaxis.

C.Difficile rates per 100,000 bed days


Period Best Worst Average Period New Hall2012/13 Several 0 RNA 58.2 Eng 22.2 2012/13 NVC09 0.02013/14 Several 0 RVW 30.8 Eng 17.3 2013/14 NVC09 0.0


We have a good record in infection prevention and control Antimicrobial prescribing is in line with Ramsay policy and CCG formulary


To ensure patients’ VTE requirements are assessed and patients receive appropriate prophylaxis.

Incident rate, patient safety

Period Best Worst Average Period New Hall2012/13 RP6 2.6 TAJ 84.4 Eng 13.5 2012/13 NVC09 6.562013/14 RRF 2.0 RAT 85.6 Eng 14.8 2013/14 NVC09 6.7


We provide elective and non emergency elective care for spinal patients with significant co-morbidities.

There is an effective pre admission process to ensure patients condition is optimised prior to surgery


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


Period Best Worst Average Period New HallJan-14 Several 100 RPA02 27 Eng 73 2012/13 NVC09 86Feb-14 Several 100 RPA02 18 Eng 73 2013/14 NVC09 100


Actively encourage patients to undertake the friends and family test The test has now been expanded to outpatients to gain an overall picture

of the hospital rather than just inpatients.


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.

Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below.

3.2.1 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 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.

Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored.

Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a Corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year.

A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice.

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 Commitee led by a Consultant Microbiologist. This meets quarterly and reports to the Clinical Governance Commitee and corporate infection control commitee.

Spots checks on all staff of hand hygiene practice using a UV light box.

A regular programme of audit covering all aspects of infection control as well as spot checks on cleaning practices by the Senior Management Team.


2011/12 2012/13 2013/140

0.10.20.30.40.50.60.70.80.9

Infection Rates

New Hall Hospital

Infe

ction

Rat

es

(per

cent

age

of A

dmiss

iosn

s)

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 non emergency cases

3.2.2 Cleanliness and hospital hygieneAssessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE)

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 main purpose of a PLACE assessment is to get the patient view.

The chart below shows the four domains of the assessment against the overall Ramsay score.

Site Name Site Type Cleanliness Food and Hydration

Privacy, Dignity and Wellbeing

Condition Appearance and Maintenance

NEW HALL HOSPITAL

Acute/Specialist 93.71% 95.96% 87.69% 85.29%

Ramsay Overall Average 95.95% 89.21% 88.62% 89.45%


New Hall has had a significant refurbishment programme since this PLACE audit took place and will strive to improve in all domains.

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.

Activities during 2013/14 All incidents recorded in a timely manner on Ramsay electronic

risk reporting system (riskman). This are reviewed and analysed by the senior management team, at Clinical Governance and health and safety meetings. Actions plans are developed in response to concerns raised and shared with appropriate staff.

CCTV is now insitu that covers all external areas of the hospital An automatic bed pusher is now 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.

3.3 Clinical effectivenessNew Hall 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.

2011/12 2012/13 2013/140

0.10.20.30.40.50.60.70.80.9

Return to Theatre Score

New Hall Hospital

Retr

nn to

The

atre

(Per

cent

age

of A

dmiss

iosn

s)

As can be seen by the graph above the number of returns to theatre has increased year on year but is still low. The increase may be due to the increasing complexities of the procedures undertaken. All returns to theatre are entered onto riskman and analysed for trends by the senior management team and Clinical Governance teams. All returns to theatre will continue to be monitored and actions taken as required.

3.3 Patient experienceAll 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 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 surveys Care pathways – patient are encouraged to read and participate in their plan

of care

3.3.1 Patient Satisfaction SurveysOur patient satisfaction surveys are managed by a third party company called ‘Qa Research’. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient’s views.

Every patient is asked their consent to receive an electronic survey or phone call following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services. Any text comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital Manager within 48hrs of receiving them so that a response can be made to the patient as soon as possible.


2012/13 2013/140

20

40

60

80

100

94.7 93.0

Satisfaction ScoresNHS/Private Patients

New Hall Hospital

Satis

facti

on S

core

s

As can be seen in the above graph our patient satisfaction rate has dropped slightly but is still good. This may be due to the significant disruption due to the extensive refurbishment undertaken.

3.4 New Hall Hospital Case Study

In order to understand what we can do better from a patient perspective we have set up a patient participation group. This is where a cross section of people who have used the service are invited to discuss their and that of their relatives/carers experience during their hospital stay. As a result we will be able to develop action plans that take into account their perspective of care given and make positive changes as required.

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.


Appendix 1

Services covered by this quality account

New Hall Hospital

New Hall Hospital/Treatment Centre has 48 beds and 3 theatres (2 with laminar flow).

Patients’ requiring level 2 care are treated and cared for by a well trained team of staff in a dedicated level 2 facility.

New Hall provides care and treatment for children over the age of 16. We see children in OPD for consultation only. On site facilities include Radiology, Physiotherapy, Mobile MRI and Pharmacy. We also provide a satellite out patient services at Dorset and Poole County Hospital

New Hall Hospital is set in beautiful grounds. 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 is courteous and professional.

Regulated Activities

Location: New Hall Hospital, Bodenham, Salisbury, Wiltshire SP5 4EY Tel: 01722 435142

Registered Manager: Fiona Taylor

[email protected]

Regulated Activities – New Hall Hospital

Services Provided Peoples Needs Met for:

Treatment of Disease, Disorder

Or injury

Bariatrics, Dermatology, General medicine, Neurology, Oncology, Paediatrics (outpatient consults only), Pain management, Physiotherapy, Psychiatry (outpatients only), Psychology, Orthopaedic medicine, Rheumatology, Sports MedicineSatellite Out patient services being carried out at Dorset County Hospital and Poole Hospital for Dorset PCTOutreach clinics at Blandford Community Hospital for spinal and orthopaedic consultation.

All adults 18 yrs and over, and young persons 16-18 yrs

Children 0-16 yrs outpatient consultation only

Surgical Bariatrics, Cosmetics, Dermatology, Ear, Nose and All adults 18 yrs and over, young persons 16-18yrs


Procedures Throat (ENT), Gastrointestinal, General surgery, Gynaecology, Ophthalmic, Orthopaedic, Oral maxillofacial, Urological, Ambulatory, Day and Inpatient Surgery

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.

Diagnostic and

screening

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

All adults 18 yrs and over, young persons 3-18yrs

Family Planning Services

Gynaecology patient pathway, insertion and removal of inter uterine devices for medical as well as contraception purposes

All adults 18 years and over as clinically indicated


Appendix 2 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month.


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

or

http://www.newhallhospital.co.uk


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