quality account 2016/17 - nhs · quality accounts 2016/17 page 4 of 67 introduction to our quality...

The Yorkshire Clinic Quality Account 2016/17

Contents

Introduction Page

Welcome to Ramsay Health Care UK and The Yorkshire Clinic

Introduction to our Quality Account

PART 1 – STATEMENT ON QUALITY

1.1 Statement from the General Manager

1.2 Hospital Accountability Statement

1.3 Welcome to The Yorkshire Clinic

PART 2

2.1 Priorities for Improvement

2.1.1 Review of Clinical Priorities 2016/17 (looking back)

2.1.2 Clinical Priorities for 2017/18 (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 2016/17 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account Indicators

3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

3.5 Case Study

Appendix 1 – Services Covered by this Quality Account

Appendix 2 – Clinical Audits

Quality Accounts 2016/17 of 67

Welcome to Ramsay Health Care UK

The Yorkshire Clinic Hospital is part of the Ramsay Health Care Group

Statement from Mark Page, Chief Executive Officer, Ramsay Health Care UK “The delivery of high quality patient care, service and outcomes remains the highest priority to Ramsay Health Care. Our clinical staff and consultants are critical in ensuring we achieve this across the whole organisation. We remain committed to delivering superior quality care and services throughout our hospitals, for every patient, every day. Everyone across our organisation is responsible for the delivery of clinical excellence and our organisational culture ensures that the patient remains at the centre of everything we do. At Ramsay we recognise that our people, staff and doctors, are the key to our success and that teamwork and communication is critical to meeting the expectations of our patients Whilst we have an excellent record in delivering quality patient care and managing risks, the Ramsay Health Care UK continues to focus on improvements that will keep it at the forefront of health care delivery. I am very proud of Ramsay Health Care’s reputation as a global leader in the delivery

of safe and quality care. It gives us pleasure to share our results with you.”

Mark Page

Chief Executive officer

Ramsay Health Care UK


Introduction to our Quality Account

This Quality Account is The Yorkshire Clinic’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 all 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 1

1.1 Statement on Quality from the General Manager

Debbie Craven, General Manager

The Yorkshire Clinic

“The Yorkshire Clinic appreciates that you can choose your healthcare provider and therefore is consistently committed to offering the highest quality of care and clinical outcomes for our patients”

Our Vision is to be the Leading Healthcare Provider where clinical excellence, safety, care and quality are at the heart of everything we do, whilst growing our business and profitability.

This Quality Account by The Yorkshire Clinic has been produced to demonstrate our continued commitment to measuring and acting on feedback from all our patients and customers about their experience with the intention to continually learn and improve on all aspects of the services we provide.

We are aware that patients can be anxious about coming into hospital and understand that providing reassurance is very important to you the patient and your family. This starts with patient safety, which is always our highest priority. To this end we continually review our clinical care standards, outcomes and feedback, through audit and observation and through regular open, analytical review with a “no blame” approach, which helps promote a healthy learning culture.

In addition we recruit, induct and train our team to enable the delivery of the highest standards in all aspects of clinical and customer care. This approach extends to family and visitors in ensuring they are made to feel welcome at The Yorkshire Clinic.

The Yorkshire Clinic is committed to ensuring that patients are kept fully informed about their treatment, which is also a significant factor associated with improving treatment outcomes. We involve our patients in treatment decisions at the earliest stage so that the options and benefits are fully discussed before patients consent to treatment. Our medical and clinical teams recognise the importance of devoting time preparing patients for surgery, which not only reduces risk but also improves patient understanding and confidence, reduces anxiety, improves rates of recovery and shortens lengths of hospital stay. Our care extends to the post discharge period, where we offer post discharge support and guidance 24 hours a day to provide you with ongoing reassurance.

Whilst patient feedback and involvement is extremely important to us, we also rely heavily on other measures of safety and clinical effectiveness which we use to satisfy ourselves that treatment is evidence-based and delivered by appropriately qualified and experienced doctors, nurses and other key healthcare professionals. Examples of these are detailed in this Quality Account.

The Yorkshire Clinic is accustomed to the disciplines of regulatory and contractual requirements to assure Healthcare Commissioners of our clinical performance and to report complaints and serious incidents to Regulators and Commissioners. We also maintain a Risk Register and systematically review specific actions to achieve risk reduction.


The Yorkshire Clinic’s “Friends and Family” patient satisfaction scores continually achieve over 99% for “would recommend to others”. This is consistent with the other local private hospitals and is higher than that of our local NHS Trust Hospitals. By analysing the results throughout the year, we constantly seek ways to further improve the patient experience. We achieve this through our regular Customer Feedback Forums and our planned Patient Focus Groups.

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.

Debbie Craven

General Manager

The Yorkshire Clinic Hospital


This report has been reviewed and approved by:

Mr Richard Grogan - Clinical Governance Chair

Helen White – Regional Director North


1.3 Welcome to The Yorkshire Clinic

The Yorkshire Clinic is a private hospital situated in the grounds of Cottingley Hall in Bingley, West Yorkshire. The hospital offers care to patients with private medical insurance, patients who wish to fund their own treatments and patients referred through the NHS Patient Choice Scheme. The hospital has 56 beds and 12 ambulatory bays. Facilities include five operating theatres, endoscopy unit, angiography suite, physiotherapy, pharmacy, and central sterile service department (CSSD), radiology and out-patient diagnostic facilities. The Lodge is a separate building but still part of the hospital; which has one theatre, consulting and treatment rooms and is the dedicated Ophthalmology Centre. The Yorkshire Clinic provides surgery, services for children and young people, outpatients and diagnostic imaging.

The hospital provides a full range of high quality services, these include, outpatient consultation, outpatient procedures, investigations/diagnostics, surgery and follow up care. During the last 12 months the hospital has treated 14,078 patients, 83% of which were treated under the care of the NHS. The Yorkshire Clinic has 366 members of staff with a split of 128 non-clinical staff and 238 clinical staff. We have 194 Consultants who work at The Yorkshire Clinic through approved Practising Privileges. We offer a range of services which include General Surgery, Oncology, Gynaecology, Bariatric Surgery, Urology, Cardiology, Pain Management, Gastroenterology, Cosmetics and Plastic Surgery, Orthopedic, Paediatric and Dermatology. Nursing and Medical Care at The Yorkshire Clinic: On admission all our patients are allocated a ‘named nurse’, the role of the named nurse is to provide co-ordinated care, support and treatment which is personalised to meet individual patient needs. The named nurse approach enables our patients to identify one nurse who is specifically and consistently responsible for their overall nursing care. In 1992 the Department of Health issued the Patients Charter in which the requirement for all inpatients to have a designated ‘named nurse’ was specifically mentioned. More recently the Francis report into Mid Staffordshire (2013) also highlighted the advantages of having such a system in place but took the requirement further by stating that a ‘named nurse’ needed to be designated for each shift, this is the model used at The Yorkshire Clinic. This was welcomed by the Royal College of Nursing that believes the ‘named nurse’ model provides a useful way to organise work around the needs of the patient (RCN 2014). Care and treatment provided at The Yorkshire Clinic is Consultant led. We have an RMO (Resident Medical Officer) who supports the Consultants and together with the nursing team, provides round the clock medical support to all our patients. The hospital has built excellent working relationships with our local Commissioner, Bradford Teaching Hospitals Foundation Trust, Leeds Teaching Hospital NHS Trust and Airedale Foundation Trust in order to deliver a joint approach to patient care delivery across the patient economy. Our GP Liaison Officer provides links to local General Practitioners to ensure that their needs and expectations are managed and through these links, referral


processes are developed in order to streamline processes. The GP Liaison Officer’s key role is to engage with local healthcare professionals within the community to ensure they are fully aware of the services on offer at The Yorkshire Clinic and have access to any information that can assist General Practitioners and medical staff when referring into a secondary Care Provider. Part of the GP Liaison’s role is to co-ordinate the post graduate programme which runs on a monthly basis and covers a range of topics from orthopaedic surgery to cardiology. The Yorkshire Clinic also works with charities within the local community, hosting events in their support. The Clinic supported the Northern Cleft Foundation for 2016, managing to raise £2,371. The Clinic has chosen to support Aireborough Supported Activities Scheme and Bosom Friends (Bradford) in 2017. These are both local charities and were decided by a vote through nominations received and discussed through our Staff Engagement Committee.


Part 2

2.1 Quality priorities for 2017/18

Plan for 2017/18

On an annual cycle, The Yorkshire Clinic develops a Hospital and Clinical Strategy which sets 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, our hospital and clinical strategy is driven by our commitment to ensure that quality is at the heart of everything we do. As a leading Independent Healthcare Provider we aim to continuously improve quality, safety and patient experience. Our strategy priorities are determined by the hospital’s Senior Management Team and our people (Department Heads and their team) taking into account patient feedback, audit results, National guidance, and the recommendations from various local and National 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. The public inquiry at Mid Staffordshire NHS Foundation Trust is a stark reminder that patients must come first with care delivered by compassionate and dedicated staff. At The Yorkshire Clinic the patient experience is at the heart of everything we do within the hospital. We want to know what matters to our patients, their relatives and carers so we can enhance the quality of our services.

Our Vision is to be the Leading Healthcare Provider where clinical excellence, safety, care and quality are at the heart of everything we do, whilst growing our business and profitability. Our Quality Improvement Programme focuses on three domains: patient experience, patient safety and the clinical effectiveness of care and treatment. Our Quality Account seeks to provide accurate, timely, meaningful and comparable measures to allow our partners to assess our success in delivering our vision. People are at the centre of how we ensure we operate safely – all united in a common purpose to achieve zero avoidable harm. To support our employees to achieve this goal, we have mandatory systems and processes across The Yorkshire Clinic to protect and care for all of our patients, members and our own people.


2.1 Priorities for Improvement

2.1.1 Review of Clinical Priorities 2016/17 (looking back)

We chose the following key strategies last year in which to focus:

1. Clinical Governance 2. Human Factors - learning from Never Events (safer surgery & leadership in theatres)

Clinical Governance

Our clinical governance overarching framework provides a plan for continued development and enables board to ward communication which will ensure care and that services delivered at The Yorkshire Clinic are:

• Safe

• Caring

• Effective

• Responsive

• Well led

Quality Governance at The Yorkshire Clinic is defined as the combination of structures and processes which will lead on the hospitals quality performance including:

• Ensuring accountability for quality and that required standards are achieved.

• Investigating and taking action on sub-standard performance.

• Identifying and managing risk to quality care.

• Ensuring the hospital culture supports engaging effectively on quality to plan and drive improvement.

What do we want to achieve?

As a hospital in 2016 we will ensure we are safe, effective, caring, responsive and well led (Care Quality Commission 2014).

Our Achievements:

Safety:

1. Placing Safeguarding at the heart of everything we do. We will, through staff

training and raising awareness, ensure we protect people from abuse and avoidable

harm.

Action taken: The Yorkshire Clinic has implemented an e-learning platform for Safeguarding Training and awareness which includes the following modules.


Course Staff Group

Safeguarding Adults Level 1 - E Learning & Assessment

All staff

Safeguarding Adults Level 2 - E Learning & Assessment

All Staff

Safeguarding Adults Level 3 - Face to Face Key Senior Clinicians & Safeguarding Lead

Safeguarding Children Level 1 - Introduction to Safeguarding

All Staff

Safeguarding Children Level 2 - Part A - Recognition Registered Children Nurses and Safeguarding Leads

Safeguarding Children Level 2 - Part B – Response in Secondary Care

Registered Children Nurses and Safeguarding Leads

Safeguarding Children Level 2 - Part C – Record in Secondary Care


Safeguarding Children Level 3 – Adolescent Presenting with Intoxication


Safeguarding Children Level 3 – Disability & Neglect Registered Children Nurses and Safeguarding Leads

Safeguarding Children Level 3 – Fabricated & Induced Illness


Safeguarding Children Level 3 – Attaining & Maintaining Safeguarding Competencies


Safeguarding Children Level 3 – Management of the Sudden Unexpected Death of a Child


Safeguarding Children Level 3 – Parental Risk Factors


Safeguarding Children Level 3 – Unexplained Injuries Registered Children Nurses and Safeguarding Leads

2. We will continue to support our staff with training to help them recognise when

patients or others in our care, may have difficulty in making judgements, or they lack

capacity to consent to treatment or are otherwise vulnerable. In 2016 we aim to have

100% of relevant staff compliant with Mental Capacity and Safeguarding Training.

Action taken: Training has been provided to raise staff awareness on The Mental Capacity

Act & Deprivation of Liberty safeguards.

Staff at The Yorkshire Clinic have completed face to face training in a number of areas which

has enhanced their knowledge of Safeguarding Vulnerable Adults and Children.

Training completed:

• Children’s Safeguard Training (NSPCC): Level 3- 100%

• Adult Safeguarding Training: Level 3 - 100%

• Dementia Training delivered by the Alzheimer’s Society- 100%

• Mental Capacity and Deprivation of Liberty Safeguards (DoLs)- 100%


We have: A Lead for Adult Safeguarding who sits on the Bradford Adult Safeguarding Board. The Lead communicates any safeguarding matters to the wider team through our Clinical Governance Committee. A Lead for Children Safeguarding who sits on the Bradford Children’s Safeguarding Board. The Lead communicates any safeguarding matters to the wider team through our Paediatric Governance Committee. Flow Charts in all our departments (clinical and non-clinical), which direct staff on management of safeguarding concerns (Children, Adults, Prevent). An Education Board dedicated to ‘Safeguarding Communication’ which is visible to all our staff. A Dementia Lead and Dementia Champions in key departments (Theatre, Wards, Pre-assessment, Angio, The Lodge, Radiology, Outpatient, Physiotherapy, Reception). They champion care to meet the needs of this group of patients from ensuring the environment is suitable to staff awareness on how to ensure patients receive care that is caring and compassionate, meeting their individual needs.

All our patients over the age of 75 have a Dementia Risk Assessment completed as part of their pre-

assessment, this enables us to ensure we can put into place care that is individualised to their needs.

The risk assessment may direct us to make changes to the patient’s environment to enhance safety or

we may need to put in place additional nursing support for the individual patient.

There are key Ramsay Policies that our staff use to support safe practices, these policies provide

guidance and key material that can be used to manage a safeguarding concern (these have been

updated in 2016):

• CN024 - Mental Capacity

• CN034 - Deprivation of Liberty and Safeguard

• CN037 - Safeguarding Adults at Risk of Abuse and Neglect • CN045 - Safeguarding of Children and Young People

3. Continued delivery of education and training on prevention and control of infection

so that staff understand their responsibilities and action to take.

Action taken: Mandatory Infection Prevention training consists of:

1. Staff complete mandatory e-learning module on ‘Infection Prevention’ annually.

2. Staff complete a face to face training session on ‘Infection Prevention’ this includes a

hand hygiene assessment.

3. Staff who undertake any care that requires ‘asepsis’ have completed ANTT (aseptic

non touch technique) training.

4. Urinary Catheterisation training

5. Infection Prevention Classroom Mandatory Training - topics include the importance of

hand hygiene; standard precautions; healthcare acquired infections; infection control

policy; environmental hygiene; decontamination; Personal Protective Equipment,

Health Surveillance and the safe handling and disposal of sharps. Issues regarding

waste and linen are also included. The role, responsibilities and contact information

for the Infection Prevention Lead Nurse is given.


4. Review and improve internal processes and systems to enable high standards in

infection prevention.

Action taken: We formulated a 2016-2017 Infection Prevention and Control Annual Plan

which set our strategy to facilitate best practice in infection prevention and control in order to

maintain and meet the Health and Social Care Act 2008 ‘Code of Practice on the Prevention

and Control of Infections and Related Guidance’ (July 2015).

We have appointed an Infection Control Lead Nurse (ICLN) Our ICLN leads and supports a

team of Infection Control Link Practitioners in the hospital who are integral in delivering our

annual plan.

The Yorkshire Clinic Infection Prevention Team consists of:

Hospital Matron Jan Matin (Matron) is responsible for reporting to the Group Clinical Governance Committee: healthcare associated infections, outbreaks of infection, serious untoward incidents and progress against the IPC Annual Plan. Infection Control Doctor Dr Miles Denton, Consultant Microbiologist is our Infection Control Doctor. Dr Denton has responsibility for working with Matron and the ICLN to support the implementation of the IPC Annual Plan and provide guidance and support in the Microbiology services; he also undertakes staff IPC education sessions. Infection Control Link Nurse (ICLN) Claire Manley, Infection Control Link Nurse (ICLN) will assist Matron in the delivery of the local Infection Prevention and Control Annual Plan and undertake the hospital lead role as the Infection Prevention and Control Link Nurse. The ICLN will provide education and training throughout the hospital, undertake a programme of audits, SOP formulation, alert organism surveillance, Root Cause Analysis and provide infection control support as required by the Care Quality Commission’s Criterion 8 on Cleanliness and Infection Control and the Code of Practice for the Prevention and Control of Healthcare-associated Infections (DH,2010). Departmental Infection Prevention and Control Practitioners These are frontline staff who engage in infection control activities in their area which include completing the frontline engagement audits (hand hygiene, medical devices and environmental assurance) as well as acting as role models and conduits for infection control issues. There will be nominated Infection Prevention and Control Practitioners for: Ward, OPD, Angiography/Cardiology, Physiotherapy, MR/CT/Radiology, HDU, Theatre /Recovery, Decontamination, Endoscopy, Housekeeping, Catering/Hostess and Maintenance. Antimicrobial Pharmacist Adam Tatari is our antimicrobial pharmacist. Key responsibilities of the role are: leading and reporting progress on antibiotic prescribing and management in the hospital; supporting antimicrobial stewardship by working closely with clinical teams; carrying out audits in line with national guidance; providing training with regard to antimicrobial stewardship to clinical staff; supporting the development and monitoring of antimicrobial policies with Consultant Microbiologist and clinical teams. We have:

• Standardised cleaning schedules in all our departments where cleaning is undertaken in line with a Matrix (between patient use, daily, weekly, monthly) the cleaning schedules direct staff on how to clean and what to clean with.


• New hand gel dispensers in focused areas to encourage patients, staff and visitors to use ‘hand gel’.

• We have hand hygiene posters which are changed every 3 months to ensure ‘Hand Hygiene’ remains a key focus to our patients, staff and visitors.

5. Enhance surveillance of infections and learning through action

Action taken: Our Infection Control Lead Nurse, with the Link Practitioners, monitors all

patients to ensure we capture any potential infections. This can be in-patients or patients

following discharge. We have a nominated member of the clinical team who monitors all

patients following hip and knee surgery up to 30 days post discharge. If we identify an

infection, our lead nurse completes a root cause analysis to identify areas for improvement

and where practice may need to change in line with guidance and policy.

The hospital reports infections via the NHS Public Health England Surgical Site Surveillance

System.

Our Surveillance Programme captures any patients with infections and learnings are

communicated through our Infection Prevention Committee which is chaired by our

Consultant Microbiologist.

6. Ensure appropriate use of antimicrobial prescribing

Antibiotic resistance poses a significant threat to public health, especially because antibiotics

underpin routine medical practice.

Action taken: The Yorkshire Clinic has developed an ‘Antibiotic Formulary’ this has been

benchmarked with the Bradford and Airedale Formulary to enable consistency in prescribing

thus enhancing patient safety.

The Yorkshire Clinic antibiotic prescribing is in line with NICE guidelines on antimicrobial

stewardship: systems and processes for effective antimicrobial medicine use. (Aug 2015)

Prescribing practice is audited monthly by our Pharmacy Manager to ensure all prescribing is

line with the formulary.

7. Developing our people through core training, including areas that support Duty of

Candour, such as Human Factors Training and Root Cause Analysis Training.

Supporting education and Continuous Professional Development which will enable

key staff to develop knowledge and skill in key specialist areas (e.g. Medical,

Colorectal, Critical Care and Oncology)

Action taken: Ramsay Healthcare has a robust training programme supporting education

and Continuous Professional Development via a training academy.

In 2016 the Ramsay Academy has supported staff at The Yorkshire Clinic in completing

training in the following key areas:

• Aspiring Leaders

• Head of Department Development Programmes

• Root Cause Analysis

• Duty of Candour and its Application

• Human Factors ‘The SHEEP Model’.

• Completing Appraisals


Through training and professional development programmes we have supported a

number of clinical staff in developing in their roles to become ‘specialist nurses’:

• Bariatric Nurse Specialist

• Chemotherapy Nurse Specialist

• Blood Transfusion Lead Nurse

• Resuscitation Lead

These staff members support our services to ensure safe, effective care delivery which is

evidenced based and current.

Caring: 1. Ensuring that those we engage are delivering our services in line with the Ramsay

Healthcare ‘Values’ which incorporate the need to treat people with compassion,

kindness, dignity and respect. We will do this by providing training on ‘Customer

Excellence’ and through responding to patient feedback and audit.

Action taken: All staff at The Yorkshire Clinic receive Customer Excellence training; this is

mandatory and led by Matron. The aim is to engage with our people and ensure care

delivered at The Yorkshire Clinic is delivered with compassion, kindness, dignity and respect.

The Training consists of:

• Achieving Customer Excellence the ‘Ramsay’ way.

• Difference between providing a good experience vs. providing a good service. How

do get from Good to Great?

• Our 10 point pledge to our Private Patients.

• When we get it wrong: Seven Steps to Good Complaints Management

Patient feedback is pivotal to the ongoing success of The Yorkshire Clinic as we believe by

acting on feedback provided by our patients we can improve our services and care delivery.

All patient feedback is reviewed and analysed at our Customer Focus Group Meetings. At

this meeting we look for trends and themes and develop actions to improve practices,

processes, services and care delivery based on the feedback received from our patients.

We capture patient feedback through the following methods:

1. All Patients are requested to complete a Friends and Family Test recommendation

as per the NHS directive. The results from the survey are collated and inputted onto

the Corporate database. A monthly report is then circulated to all General Managers

in order to disseminate and track performance and results.

• We take action from points where our patients have indicated dissatisfaction in

our care or services.

• We commend staff that have received positive feedback on the care they have

provided.

• We communicate our Friends and Family feedback to our teams to ensure

they are fully informed of ‘what our patients are saying about our care and

services’.


2. ETabs (Ramsay Electronic Patient Satisfaction Survey, PSS) which is the Ramsay

Electronic Patient Feedback System. This system reports weekly patient feedback

which highlights positive and negative patient feedback. Patients are asked to leave

the contact details enabling a member of the Senior Management Team at The

Yorkshire Clinic to respond to the feedback. Where patients raise a concern in the

feedback our Quality Improvement Manager contacts the patient and ensures action

taken and lessons learnt.

3. Patient Focus Group: The Yorkshire Clinic has established a Patient Focus Group. The Group consists of 8 Patients, Matron, Ward Manager and Quality Improvement Manager. At the meeting we discussed the patient’s journey individually to identify good practices and areas for improvement.

4. NHS Choices: Our patients are encouraged to provide ‘feedback’ through NHS Choices; the feedback is reviewed and actioned through our Customer Focus Group meetings.

5. Social Media: We actively seek patient feedback through social media (Facebook). The Yorkshire Clinic has a ‘Facebook page’ where patients leave feedback and we can respond to their comments.

3. Improvement of the patient experience and excellent clinical outcomes for

patients with a culture of continuous improvement in order to both reduce

variation and improve overall quality of care. Doing the right things in the right

way, innovating and ensuring our teams base their practice on the best

available evidence.

Action taken: To ensure continuous monitoring of patient experience and excellent clinical

outcomes based on best available evidence and research The Yorkshire Clinic developed a

‘Meeting Structure’ to support the Governance Framework. The meeting framework below:

• Provides assurance that The Yorkshire Clinic has an effective and responsive

structure in place for governance, which is supporting the organisation’s programme

for quality improvement and informing the Board on quality and performance.

• Provides assurance that The Yorkshire Clinic has effective processes in place for

quality improvement in clinical services.

• Provides focus on accountability arrangements, strategic planning and reporting and

communication.

• Provide a clear framework where the objectives set in this strategy can be discussed,

actioned, monitored and evaluated to ensure full compliance is met.


3. A patient centred and patient led approach to care, treating patients courteously,

listening to them, keeping them informed and involving them in decisions about their

care (no decision about me without me – DH 2010). The creation of an environment of

openness, honesty and candour in which problems are prevented, detected quickly

and addressed firmly

Action taken: All patients are admitted and treatment/care planned individually in order to

understand individual needs. The Yorkshire Clinic have commenced using departmental

customer care standards in order to ensure consistent customer service excellence.

Effective:

In 2016 we will focus on our Paediatric Service to ensure the care we deliver is safe,

effective and well led. We will do this by:

1. Recruiting a Paediatric Lead Nurse who leads with skill, experience and knowledge.

Action taken: The Yorkshire Clinic has recruited an experienced Paediatric Lead Nurse who

started in August 2016. Our lead nurse has acute surgical experience and has supported

Matron in ensuring the care and services delivered to Children and Young People is safe,

caring, responsive, effective and well led.

This is evidenced by our Care Quality Commission Report who rated The Yorkshire Clinic’s

Children and Young People Services as ‘Good’ overall and ‘Good’ across the safe, caring,

responsive, effective and well led domains.

2. Facilitating a dedicated Paediatric Governance Committee to focus on maintaining

quality and ensuring safe outcomes.

Action taken: The Yorkshire Clinic has a dedicated Paediatric Governance Committee

which is led by a Consultant Paediatrician and supported by a Consultant Surgeon,

Consultant Paediatric Anaesthetist, Matron, Paediatric lead nurse and Children Nurses

(RSCNs). The Committee meet quarterly and ensure care and services delivered to Children

and Young People are safe, effective, responsive, caring and well led.

The following is discussed and reviewed to ensure quality and safe outcomes within

this speciality:

• Review of admissions by speciality to ensure patient journey in line with best practice and Ramsay Care of the Child Policy (CN011)

• Review of Incidents/ Complaints

• Compliance to CQC Children’s Framework, Ramsay Care of the Child Policy (CN011) and NCEPOD (surgery in children: Are we there yet? 2011)

• Staff training and competencies review

• Patient satisfaction

• Audit


3. Ensuring all our staff who care for children and young adults are competent and

comply with best practices at all times.

Action taken: All staff complete training to ensure they are fully equipped to care for

children and young people. Training is tailored to individual job roles to ensure children and

young people receive safe, effective care by competent staff.

Our training matrix below indicates who does what to maintain competence.

Training Staff Group

Paediatric Basic Life Support (PBLS) All hospital staff clinical and non-clinical

Paediatric Immediate Life Support (PILS) All Senior Nurses, Paediatric Nurses and

ODPs

Advanced Paediatric Life Support (APLS) Resident Medical Officer (RMO)

Safeguarding Children Level 1- Introduction to

Safeguarding

All Staff

Safeguarding Children Level 2 - Part A -

Recognition

Registered Children Nurses and

Safeguarding Leads

Safeguarding Children Level 2 - Part B –

Response in Secondary Care


Safeguarding Leads

Safeguarding Children Level 2 - Part C – Record

in Secondary Care


Safeguarding Leads

Safeguarding Children Level 3 – Adolescent

Presenting with Intoxication


Safeguarding Leads

Safeguarding Children Level 3 – Disability &

Neglect


Safeguarding Leads

Safeguarding Children Level 3 – Fabricated &

Induced Illness


Safeguarding Leads

Safeguarding Children Level 3 – Attaining &

Maintaining Safeguarding Competencies


Safeguarding Leads

Safeguarding Children Level 3 – Management of

the Sudden Unexpected Death of a Child


Safeguarding Leads

Safeguarding Children Level 3 – Parental Risk

Factors


Safeguarding Leads

Safeguarding Children Level 3 – Unexplained

Injuries


Safeguarding Leads

Leadership:

1. Promotion of a culture of safe, compassionate care with a reduction of the risk from clinical errors and adverse events, as well as a commitment to learn from mistakes and share that learning.

Learning from incidents - ‘A culture of openness and transparency’ has been a focus in 2016. The Senior Management Team have delivered a number of staff forums where staff have been encouraged to report incidents, share learning and learn from mistakes. A ‘no blame culture’ is encouraged and staff are informed that they we are committed to learn from mistakes and share learning.


We have:

Provided re-training on Riskman (our incident reporting system) to clinical and non-clinical

staff to improve our incident reporting. This has shown a significant increase in our incident

reporting:

July 2016 (staff re training)

August 2016 September 2016

17 50 52

• Heads of Department analyse all incidents reported per month in their department and develop a report with clear actions, lessons learnt. This report is discussed at Clinical Governance Committee and to individuals at department meetings, staff who have reported the incident are communicated the outcome and actions taken.

• Incident reporting ‘education board’ displayed on ground floor corridor which provides staff with information on the importance of reporting an incident, examples of incidents, how to report an incident and what happens when an incident is reported. The number of incidents reported, trends and actions per month is also displayed to ensure all staff learn from incidents and there is a culture of openness and transparency.

We have further completed training with our staff to ensure they fully understand ‘The Being Open Framework (National Patient Safety Agency 2009) ’ and apply Duty of Candour in everyday practice.

2. An environment which is safe for both patients and staff and supports their needs and wellbeing. Assurance that the clinical service is well managed, well led and compliant with regulatory requirements. Strong leadership, accountability and engagement of our staff throughout the hospital, both clinical and non-clinical.

Action taken: To ensure The Yorkshire Clinic can evidence safety for both patients and

their staff enabling safe, effective, caring , responsive and well led services throughout the

hospital we have a robust Governance Framework which:

• Provides assurance that The Yorkshire Clinic has an effective and responsive

structure in place for governance, which is supporting the organisation’s programme

for quality improvement and informing the Board on quality and performance.

• Provides assurance that The Yorkshire Clinic has effective processes in place for

quality improvement in clinical services.

• Provides focus on accountability arrangements, strategic planning and reporting and

communication.

• Provides a clear framework where the objectives set in this strategy can be

discussed, actioned, monitored and evaluated to ensure full compliance is met.

Quality Governance is described by Monitor (2010) as the combination of structures and

processes at and below board level to lead on hospital quality performance including:

• Ensuring required standards are achieved;

• Investigating and taking action on sub- standard performance;

• Planning and driving continuous improvement;

• Identifying, sharing and ensuring delivery of best-practice; and Identifying and managing

risks to quality of care.


We have set up a Staff Engagement Group who focus on promoting engagement across the hospital. The group consists of Engagement Champions from each department who meet each month to discuss engagement activities. These have recently included the charities to support in 2017 and future projects include the introduction of a staff newsletter and a summer event to raise money for charity. Responsive:

1. Consistently providing care which is evidence based, safe, and effective and

adheres to best practice. The collation of data which is robust, well analysed and

used effectively.

Action taken: Within our Governance Framework we have a monthly ‘Clinical Audit and

Effectiveness Group’ who meet monthly to analyse/discuss and evaluate:

• Ramsay and local Policies.

• National Guidance (NICE, NCEPOD)

• ALERTS inc NPSA, MHRA

• PROMS (patient reported outcome measures following hips, knees and hernia

surgery

• NJR (National Joint Registry) data

• Audits (results, actions required, trends and changes in practice required)

• Incidents (trends, themes)

• Clinical Variances in patient pathway and ways to improve pathway

The Group analyse all the information and data and look at ways in which best practice can

be applied to care and services at The Yorkshire Clinic. Where improvement is required in

our services, processes and pathways following analysis of data an action plan is formulated

to enable changes to be made. The Yorkshire Clinic constantly strives to be the ‘centre of

excellence’ in everything we do by adhering to best practice guidelines and research based

practices.

2. Clearly defined, well understood processes for reviewing the assurance of, and

escalating and resolving, quality issues and performance.

Action taken: Our Governance Framework provides assurance that quality and

performance is being monitored, through the different committees set within the framework

all quality issues and performance are analysed, discussed and actioned. The framework

provides a board to ward method of communication to ensure safe, effective care at all times.

The Framework is also set to ensure committees can escalate upwards to ensure action at

Senior Management level (SMT) and to the Medical Advisory Committee (MAC).

Our Clinical Governance Committee is responsible for all aspects of quality care and risk

management which include:

• Co-ordinating of all clinical activities across all the operational risk areas

within The Yorkshire Clinic.

• Ensuring that there is a consistent approach to how policies and procedures

are developed and implemented in practice.

• Improving patient safety and outcomes.


• Reviewing national guidance (NICE, NCEPOD, NPSA) to direct best practices

within the Yorkshire Clinic.

Human Factors:

As an organisation we recognise that learning from incidents is critical to prevent recurrence.

We see human factors as a key contributor to the serious and untoward incidents we have

experienced. Through staff training, monitoring behaviours and the raising awareness of

human factors in health care we feel we will reduce the likelihood of further serious untoward

and/or “never event” incidents.

The Yorkshire Clinic has provided staff training on ‘Human Factors’ during 2016 with the aim

of “Enhancing clinical performance through an understanding of the effects of teamwork,

tasks, equipment, workspace, culture and organisation on human behaviour and abilities and

application of that knowledge in clinical settings”.

Our focus on Safer Surgery includes;

1. Using a combination of formal processes and procedures, staff team meetings, forums and informal evidence based learnings we will aim to create an environment that has greater emphasis and focus on safer surgery.

Action taken: Safer Surgery has been key within our 2016-2017 Clinical Strategy. To

ensure we equip our teams with the best tools and processes to enable safe surgery ‘Every

Time’, the Yorkshire Clinic implemented the National Safety Standards for Invasive

Procedures ( NatSIPPS) within all areas where patients undergo any invasive procedures.

The National Safety Standards for Invasive Procedures (NatSSIPs) aim to reduce the

number of patient safety incidents related to invasive procedures in which surgical Never

Events could occur. These new standards set out broad principles of safe practice and

advise healthcare professionals on how they can implement best practice, such as through a

series of standardised safety checks and education and training. The standards also support

healthcare providers to work with staff to develop and maintain their own, more detailed,

local standards and encourage the sharing of best practice between organisations.

The Yorkshire Clinic has implemented practices and processes outlined in the National

Safety Standards for Invasive Procedures (NatSSIPs) and Ramsay Healthcare have

developed more detailed local standards (LocSSIPs) which have been implemented at the

Yorkshire Clinic.

The below are standards set within the Ramsay LocSSIPs which support Safe Surgery

Practices:

1. CN006 SOP001 - List Safety Officer

2. CN006 SOP002- Safety Briefing and Debriefing

3. CN006 SOP003 - Site Marking

4. CN006 SOP004 - Stop Before You Block

5. CN006 SOP005 - Prosthesis Verification

6. CN006 SOP006 - Selection and Checking of Intraocular Lens Implants for Cataract

Surgery

7. CN006 SOP007 - Swab Count

8. CN006 SOP008- Handling and Checking Surgical Instruments

9. CN006 SOP009 - Management of Histology Specimens.

https://www.england.nhs.uk/patientsafety/never-events/natssips/

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/09/natssips-safety-standards.pdf

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/09/natssips-safety-standards.pdf


2. Theatre Manager/Deputy and Team leaders will be more regularly visible in the operating theatres to provide additional support to staff to encourage individual focus specifically with regards to the engagement of individuals completing the WHO Safer Surgery Checks.

Action taken: Senior theatre staff visibility, support for junior staff and monitoring practices through audit in theatre was key to drive safer surgery. To action this we recruited 2 ‘Theatre Coordinators’ in 2016 there role is to manage the day to day operational running of the theatre. They are supernumary which gives them the time to ensure quality and drive patient safety. In their role they:

• Are visible to staff and Consultants and can provide support, guidance when required.

• Ensure lists run in line with policies and procedures.

• Will undertake ‘spot audits’ of WHO Safe Surgery Checks to ensure staff complete these checks in line with policy.

3. Identify consultant Surgeon champions who will actively promote the focus on safer

surgery procedure both with theatre staff and their own peer group.

Action taken: We have two Consultants ; Consultant Orthopaedic Surgeon and Consultant

Anaesthetist who are our Safe Surgery Champions. They support Matron and the Clinical

team in promoting safe surgery at the Yorkshire Clinic. They will support/challenge poor

practices within their own peer group.

4. We will continue to support our staff with training to help them have more

confidence to work more effectively as a team to promote focussed safe practice. This

will include team members attending appropriate training including assertiveness and

communication skills.

Action taken: As part of the training for the implementation of the National Safety

Standards for Invasive Procedures (NatSSIPs), Matron delivered training to staff to empower

them to have courage to speak up and be heard if they observe any practices that may

compromise patient safety. The training centred on being assertive, having courage and that

they will be supported by the Senior Management Team.

5. Ongoing regular review of prior action plans and audits created from incidents to

ensure practice improvements are embedded and maintained.

Action taken: The Yorkshire Clinic have processes in place through the Governance

Committees which ensures action plans are implemented and implemented practices can be

evidenced through audit.

We continuously review our processes, services and clinical care delivery through audit.

We have an audit group that meet monthly to review action plans, re-audit where areas of

concern has arisen and plan how and who will conduct audits.

We audit objectively e.g. an outpatient nurse will complete audits for Ward etc... Objective

auditing commenced from July 2016, this had shown a decrease in our audit scores which

we understand is a true reflection of what the auditors found. In the past audits were

completed by the same people and they would audit their own areas.


Where the audit score is less than 95% an action plan is implemented promptly to address

the areas of non-compliance and then the audit is re-audited monthly until a score of >95% is

achieved.

Audits are reviewed and discussed at our Clinical Audit and Effectiveness Committee and

Clinical Governance Committee where we monitor progress on actions and ensure we are

closing the quality loop.

3.1.2 Clinical Priorities for 2017/18 (looking forward)

What do we want to achieve?

Our Hospital Strategy is driven by our commitment to ensure that quality is at the heart of

everything we do. As a leading Independent Healthcare Provider we aim to continuously

improve quality, safety and patient experience.

Our 2017-2018 Strategy will set a vision for quality at The Yorkshire Clinic. The strategy will

encompass the Care Quality Commission’s domains used when assessing the quality of a

healthcare organisation.

These Five Key domains will direct what we want to achieve:

• Safe

• Effective

• Caring

• Responsive

• Well led

Under each domain we will provide clear objectives, which demonstrate our commitment to

quality improvement and how we will achieve these objectives. Evidence and best practice

will underpin all our objectives.

Having patients and staff (our people) at the heart of everything we do, our strategic

objectives and our values will determine our quality vision for the next year.

Under SAFE we will work on Medicines Optimisation: Helping patients to make

the most of medicines.

The Yorkshire Clinic recognises that most patients will receive medicines, and most clinical staff will deal with medicines, at some stage in the care of almost every patient. This objective seeks to deliver safe and effective drug therapy and safe and secure handling of medicines to enhance public confidence in medicines and their use.

We also recognise that medicines have the potential for harm, as well as for good, and are therefore committed to ensuring that medicines are used safely and effectively.

The approach to medicines management within The Yorkshire Clinic will be proactive. It will seek to meet the changing needs of patients in the modern healthcare environment, by ensuring that:

• patients have appropriate access to medicines and pharmaceutical advice,

• patients get the best from their medicines,

• patients are not put at unacceptable risk by their medicines and patient safety is paramount.


We will do this by:

1. Developing effective systems for the safe and secure handling of medicines,

medicines procurement, the controlled introduction of new drugs etc. in accordance

with current guidance.

2. Monthly Medicines Management Committee to analyse all incidents, develop actions

and improve practices. The committee will review National Patient Safety Alerts

(NPSA) and Medicines & Healthcare products Regulatory Agency (MHRA).

3. Every in-patient will have their medicines reconciled within 24 hours of admission in

line with NICE Guidelines (NG5 2015) Medicines optimisation: the safe and effective

use of medicines to enable the best possible outcomes.

4. A random selection of drug prescriptions will be audited monthly which will evidence

safe, effective administration of medications by the clinical team in line with Nursing

Midwifery Council (NMC 2008) Safe Standards for Medicines Management.

5. Promote a safety culture around medicines use including effective use of

National and local reporting systems to report and learn from medication safety

incidents. Increase incident reporting through Riskman to enable learning and action

from incidents.

6. We will use clinical audit, education and quality improvement to improve safe and

effective care and reduce variation in health outcomes related to medicines

Management. We will do this by developing a hospital wide audit programme that

reviews ‘medicines management’ from supply, stock, storage, administration,

compliance polices and national guidelines to patient feedback. We will deliver

Medicines Management training to all staff involved and assess competency.

7. Antimicrobial Stewardship; we will continue to review and audit our antibiotic use to

ensure we are supporting the national priorities set In the 2013 annual report by

Professor Dame Sally Davies, Chief Medical Officer, who said 'Antimicrobial

resistance poses a catastrophic threat. If we don't act now, any one of us could go

into hospital in 20 years for minor surgery and die because of an ordinary infection

that can't be treated by antibiotics'. We will continue to use best practices set out by

NICE Guidelines (NG15 2015 and QS121 2016) Antimicrobial stewardship: systems

and processes for effective antimicrobial medicine use

Under EFFECTIVE we will offer all nurses and clinical practitioners Clinical

Supervision which will improve the quality and safety of patient care through staff

building on knowledge, skills through reflection and learning.

The Yorkshire Clinic is made up of a range of diverse services which are committed to

providing high quality patient centred care in all areas that we serve. This is achieved

through the efficient and effective use of resources to provide a comprehensive range of

services. Staff are our most important resource and therefore the facilitation of highly

competent, patient focused, experienced and resourceful staff is a key requirement of

achieving a high quality service.

Clinical Supervision is not a new concept and has been recommended as highly

important within documents such as the NHS plan and Darzi next stage review (2008) and

the CQC report “supporting effective clinical supervision” (2013). Reports from Robert

Francis QC and Professor Don Berwick include recommendations to improve the quality and

safety of patient care were lifelong learning, professional support and ‘just culture’. Clinical

Supervision is in an excellent position to support these activities.


Equity & Excellence white paper (DOH 2010) promotes patient choice “no decision

about me without me “and clearly aims for all Clinical staff to be world class. The wellbeing of

staff and their ability to perform at a high level of expertise is crucial to this.

The Yorkshire Clinic will ensure regular clinical supervision becomes a professional

requirement to enable quality and safety aspirations set. Clinical Supervision will be part of

the Clinical Governance Agenda, supporting safe, high quality patient care; promoting

professional development, and fostering an open culture of learning from positive and

negative events and replicating best practice.

Essentially, Clinical Supervision at The Yorkshire Clinic will allow a Clinical Practitioner to

receive professional supervision in the workplace by a skilled supervisor.

Clinical supervision will enable registered nurses and clinical practitioners to:

• Identify solutions to problems

• Increase understanding of professional issues

• Improve standards of patient care

• Further develop their skills and knowledge

• Enhance their understanding of their own practice

• Identify gaps in knowledge and practice

We will meet the Clinical Supervision requirements by:

1. Providing training to all staff on what clinical supervision is and the benefits for

them and patients.

2. Offering clinical supervision to all nurses and clinical practitioners.

3. All clinical supervisors will complete a supervisor’s training course and have the

following skills and level of knowledge:- active listening, provide constructive

feedback, be open and tolerant of others, able to provide educational and

emotional support, able to create opportunities for improvements and able to use

techniques to manage team dynamics.

4. Regular one-to-one sessions with a trained supervisor.

5. Group supervision within teams.

6. Meeting up with colleagues in a local professional group.

Driscoll (1994) Model of reflection will be used


Under RESPONSIVE we will introduce a Patient Diary to capture patient feedback

throughout their journey with us.

The Yorkshire Clinic is very keen to learn what the patients experience has been throughout

there pathway, this enables us to learn and take action where improvements are required.

We want to be responsive to every patients needs to ensure we are providing care that is

individualised and to their needs.

Our patient diary will:

• Improve communication and encourage patient involvement in their care.

• Start at the point of the patient receiving their 1st out-patient consultation right through

to consultation, pre-assessment, admission and discharge.

• Involve all the teams and departments the patient comes in contact with.

• Involve patients families and friends (we value there feedback).

• Produces a full schedule of planned interventions, such as diagnostics, operative

procedure, meal times, ward rounds, medication rounds and physiotherapy, for a

patient’s stay.

Using the diary as a starting point for discussion, nurses will engage with patients and carers

daily to help manage expectations and empower patients to discuss their care and challenge

anything that they feel may have been overlooked.

By implementing patient diaries with patient views in this way, the team aims to have a

positive impact on improving the patient experience and service productivity. We will see the

patient journey through the patient which will enable us to improve our patient pathways. We

believe this is how we will achieve ‘Outstanding’ in the care and services we offer.

Under CARING we will strengthen the Fundamental Care delivery to our patients.

Meeting patients’ fundamental care needs is essential for optimal safety and recovery and

positive experiences within any healthcare setting. There is growing international evidence,

however, that these fundamentals are often poorly executed in acute care settings, resulting

in patient safety threats, poorer and costly care outcomes, and poor experiences for patients

and families.

At The Yorkshire Clinic we value fundamental care as it is these care elements that enhance

patients experience and comfort. To ensure we delivery care with compassion every time,

We will focus on:

Patient Comfort rounds - In January 2011 the British Prime Minister called for changes in the way nurses deliver care. Following a number of critical reports, concern had been expressed about the need to ensure essential aspects of nursing care are consistently delivered. One of the Prime Minister’s recommendations is for hospitals to implement hourly nursing rounds, to check on patients and ensure their fundamental care needs are met – an approach related to ‘intentional rounding’ in the United States. Within the United Kingdom some organisations refer to this type of nursing activity as “care rounds” or “comfort rounds”. In this Policy Plus we examine different approaches to intentional rounding and review available evidence.

At The Yorkshire Clinic we will develop ‘comfort rounds’ where a member of the clinical team will see patients at least every 2 hours to ensure all their personal needs are met (hygiene, elimination, nutrition, pain, environment, psychological etc..). Our healthcare assistants will ensure patients basic care needs are met.


Our focus will be on:

• Communication and information - ensuring our patients and their families are kept fully informed and they are involved in there care pathway.

• Respecting people • Rest and sleep - ensuring nursing care delivery does not disrupt patient rest and

sleep and the environment provides a peaceful. • Comfort, alleviating pain - use the pain score tool during the comfort rounds to assess

patient’s pain and take action. • Personal hygiene, appearance - all patients will be assisted with hygiene needs in the

morning and before bedtime, during the 2 hourly comfort rounds patients will be offered support to freshen up.

• Eating and drinking - we will actively promote ‘protected meal times’ and ensure patients dietary requirements are individualised to their needs. The nursing team will have a key focus on patient nutrition and hydration.

• Oral health and hygiene - our Healthcare Assistants will complete training to support patients with their oral hygiene.

Our Ward Manager will provide Ward healthcare assistance training on ‘outstanding’ fundamental care delivery.

We will use the 6Cs as our values to delivering fundamental care which will enhance patient care and comfort.

Care - Care is our core business and that of our organisations and the care we deliver helps the individual person and improves the health of the whole community. Caring defines us and our work. People receiving care expect it to be right for them, consistently, throughout every stage of their life.

Compassion - Compassion is how care is given through relationships based on empathy, respect and dignity - it can also be described as intelligent kindness, and is central to how people perceive their care. Competence - Competence means all those in caring roles must have the ability to understand an individual’s health and social needs and the expertise, clinical and technical knowledge to deliver effective care and treatments based on research and evidence. Communication - Communication is central to successful caring relationships and to effective team working. Listening is as important as what we say and do and essential for "no decision about me without me". Communication is the key to a good workplace with benefits for those in our care and staff alike. Courage - Courage enables us to do the right thing for the people we care for, to speak up when we have concerns and to have the personal strength and vision to innovate and to embrace new ways of working. Commitment - A commitment to our patients and populations is a cornerstone of what we do. We need to build on our commitment to improve the care and experience of our patients, to take action to make this vision and strategy a reality for all and meet the health, care and support challenges ahead.


How will we do this?

Training and development of all staff reflecting the 6Cs - The 6Cs are relevant to all staff, and will be embedded education and training, organisational culture and the appraisal and development of staff. We will have a lead for the 6Cs for the hospital and Champions in every department who role model and influence these values.

Under WELL LED we will develop a process where every patient’s discharge is seamless,

where patients are fully informed and are part of their Discharge Planning this will enhance

patient safety and patients experience.

Effectively managing the patient journey is crucial to improving the patient experience and discharge from hospital back into the community is an important aspect of this. Hospital discharge is a complex process with many potential sources of error and delay. Patients and family members require skills, information and confidence to ensure continuity in post discharge care. Patients at discharge are often in a vulnerable state: they are anxious, have side effects from medication, and may have functional or cognitive impairment. Discharge can also be an intense episode in the care process where patients and family members are not ready to care for the patient at home, and are confronted with difficult decisions and changes (e.g. financially and emotionally) that impact their home setting and resources. Patients, despite the recently increased focus on patient centered care often leave the hospital unprepared for post discharge demands. Many studies have found patients with complex care needs reported that they did not receive instructions for follow-up nor did they receive clear medication directions. Other studies have demonstrated that patients and family members express anxiety and a sense of abandonment after discharge. Patient unpreparedness, anxiety and a misunderstanding of the full ramifications of their situation at discharge are believed to increase hospital readmissions and adverse events in the post hospital setting. The Yorkshire Clinic recognises that to facilitate a smooth discharge from care in hospital the discharge plan must be well defined, prepared and agreed with each individual patient and there family/carer. To allow sufficient time for suitable and safe arrangements to be made, discharge planning should begin at pre-admission clinics, with a predicted date of discharge.

We will ensure every patient is discharged from the ward when clinically ready and medically

fit, in a controlled, organised and safe manner. Patients will be involved in there discharge

planning at every step of their journey.

We will do this by:

• Developing a discharge strategy group who will develop a standard for all nurses and

clinical practitioners to follow who are involved in patient discharge.

• Discharge planning will start at the Pre-admission clinic

• Involving patients and their families at every stage in their journey.

• Developing discharge packages to meet individual patient needs.

• Staff education and training.

• Discharge checklist to ensure both the clinical staff and the patient agree fundamental

goals prior to discharge.

• Discharge patients with specific information, instructions and post discharge care

tailored to their individual needs. The patient's preparedness for discharge will involve


more than physical function readiness and will include emotional, cognitive and

psychosocial readiness, as well as the readiness of family members who will be

caregivers.

• Involving community careers early in the patients discharge e.g. district nurses.

We will contact all our patients post discharge to ensure there continued recovery, help

answer any further questions that may have arisen and to assess their experience with us.

We believe through feedback we can continue to improve and deliver care and services that

enhance our patients experience and safety,

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 2016/17 The Yorkshire Clinic provided and/or subcontracted 40 NHS services.

The Yorkshire Clinic has reviewed all the data available to them on the quality of care in all of these NHS services which include:

▪ Adult Cataract Surgery NHS Clinic

▪ Adult Colorectal Surgery NHS Clinic

▪ Adult Diagnostic Endoscopy Flexi Sigmoidoscopy inc Colonoscopy NHS Clinic

▪ Adult Diagnostic Endoscopy Gastroscopy NHS Clinic

▪ Adult Elbow Only NHS Clinic

▪ Adult ENT NHS Clinic

▪ Adult Fertility & Reproductive Medicine NHS Clinic

▪ Adult Forefoot Surgery inc Bunions NHS Clinic

▪ Adult Gynaecology NHS Clinic

▪ Adult Hand & Wrist NHS Clinic (Complex)

▪ Adult Hand & Wrist NHS Clinic

▪ Adult Hernia Repair NHS Clinic

▪ Adult Hip NHS Clinic

▪ Adult Hip Revision Surgery NHS Clinic

▪ Adult Incontinence/Urogynaecology NHS Clinic

▪ Adult Knee Arthroscopy NHS Clinic

▪ Adult Knee Joint Revision NHS Clinic

▪ Adult Knee NHS Clinic

▪ Adult Laparoscopic Hernia Repair Clinic

▪ Adult Lumps and Bumps Surgery NHS Clinic

▪ Adult Menstrual Disorders Bleeding NHS Clinic

▪ Adult Shoulder only NHS Clinic

▪ Adult Minor Breast Surgery NHS Clinic

▪ Adult Minor Plastic Surgery NHS Clinic

▪ Adult Pain Management NHS Clinic

▪ Adult Urology NHS Clinic

▪ Dermatology NHS Clinic

▪ Direct Access CT Scan NHS Service

▪ Direct Access MRI Diagnostic Imaging NHS Service


▪ Direct Access Nerve Conduction Studies NHS Clinic

▪ Direct Access Non-Obstetric Ultrasound NHS Service

▪ Direct Access X Ray NHS Service

▪ Gall Bladder & Gallstones Clinic (excl Apply)

▪ Gastro Lower GI

▪ Gastro Upper GI

▪ Neurology NHS Clinic

▪ One Stop No Needle, No Scalpel, No Suture Vasectomy NHS Clinic

▪ Sleep Studies NHS Clinic

▪ YAG Laser Unit (Capsulotomy & Iridotomy) NHS Clinic

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 2016/17, the indicators on the scorecard which affect patient safety and quality were:

Score card indicators which affect patient safety and quality were:

Human Resources

Mandatory training takes place twice a month, one clinical and one non-clinical and covers the following workshops:

• Infection Control

• Fire & Medical Gasses (Clinical)

• Data Protection

• BLS (Basic Life Support) & AED (Clinical)

• Manual Handling, includes Evacuation chair procedure

• Prevent For all existing members of staff to attend annually. The workshops involve a variety of practical exercises, group activities, presentations, and self-reflection all lead by internal

2012/2013 2013/2014 2014/2015 2015/16 2016/17

Total Health Care Assistants – whole time equivalent (WTE)

21.97 22.55 36.30 39.48 43.74

Total Registered Nurses (WTE) 56.75 53.06 53.17 49.89 53.62

Total WTE Nursing (RN & HCA) 78.72 75.61 89.47 89.37 97.36

HCA hours as a % of Total Nursing Hours

28 29.8 40.5 44.17 44.9

Rolling Sickness Absence 3.66 3.89 3.66 3.74 4.39

Rolling Employee Turnover 6.0 11.8 20.2 17.7 13.4

Number of Significant Staff Injuries 1 (RIDDOR reportable )

1(RIDDOR reportable)

0(RIDDOR reportable)

0(RIDDOR

reportable)

0 (RIDDOR

reportable)


senior members of staff. The mandatory training has been separated into clinical and non-clinical to include the additional training for clinical staff members, including AED, medical gasses, and longer sessions for manual handling. We have also recently introduced a staff induction day for new starters to attend. As well as the above, this day also covers an introduction to Ramsay and The Yorkshire clinic by a member of the senior management team, a HR update that includes an overview of policies and the Allocate system and an update on the Riskman system and how to use it. We cover Customer care now as a separate workshop ran by the Ward Manager. A more in depth session that lasts half a day and covers practical examples of complaints received general customer advice and the expectations of the hospital. We have a new e-learning intranet that allows staff to complete the necessary modules most appropriate to their role. Split between clinical and non-clinical modules, these include a range of online training that employees can easily access. This will also be used to monitor Mandatory training statistics moving forwards. The new system includes further Safeguarding modules and the ability to easily track face to face training and compliance levels.

Further training is available throughout the year at a range of Ramsay Healthcare sites internally. Some of these include:

• Project Management

• Financial Awareness

• Assertiveness Skills

• Communication and Managing Meetings

• Excel – Introduction

• Surgical First Assist

• Root Cause Analysis

• Managing Change

• Quality Appointments

• Coaching & Mentoring

• Efficiency and Effectiveness We have seen a general increase in clinical staffing numbers and an increase of both Registered Nurses and Healthcare Assistants. We have continued to focus on training and development of recruited Healthcare Assistants to have additional competency skilled ability to support the Registered Nurses. With the recent introduction of the Apprenticeship Levy, we also have the opportunity for further development for Healthcare Assistants. Employee Turnover has reduced by 4%, due to increased care and focus on employee engagement and retention throughout the organisation including particular focus on the exit interview process and monitoring this feedback closely. Further attention has also been focused on the induction process for staff including the introduction of the staff induction day as outlined above. We are continuing to use wider methods of recruitment such as social media and recruitment open days at the clinic. The recent introduction of the National Living Wage companywide to all employees earning under £7.50ph should also help reduce this turnover figure further. Sickness absence has increased by over 1% and is continually monitored and reviewed at The Yorkshire Clinic. I believe this has increased due to the number of long term sickness cases recently. There are no common themes with sickness however rolling sickness is higher in clinical areas. Ramsay has recently introduced a new sickness policy from 1st May 2017 and this should help to reduce the sickness absence. Key changes include the introduction of the Bradford Score to help minimise short term absences and a reduction in the amount of CSP (Company Sick Pay) received for employees with shorter service length.


Formal Complaints per 1000 HPD's

The Yorkshire Clinic received 44 complaints from 1 April 2016 to 31 March 2017 compared

to 46 complaints in the previous year. The 44 complaints were expressions of concern,

dissatisfaction and requests for action to be taken. Complaints received were categorised as

12 complaints about medical treatment, 13 about the clinical care and 19 about the general

hospital service. All of these were investigated thoroughly complying with CQC timeframes

for response.

Every complaint received is considered very seriously and given the immediate attention of the General Manager and Matron on the day it is received, following which a thorough investigation is commenced into the concerns raised as per Ramsay Complaints Policy.

There were no EMSA (Eliminating Mixed Sex Accommodation) breaches throughout 2016/17.

Significant Clinical Events

‘Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. For further details please visit: http://www.nrls.npsa.nhs.uk/resources/collections/never-events. The core list of “never events” includes:

• Wrong site surgery

• Wrong implant/prosthesis

• Retained foreign object post procedure.

• Wrongly prepared high risk injectable medication

• Maladministration of a potassium containing solution

• Wrong route administration of chemotherapy

• Wrong route administration of oral /enteral treatment

• Intravenous administration of epidural medication

• Maladministration of insulin

• Overdose of midazolam during conscious sedation

• Opioid overdose of an opioid naive patient

• Inappropriate administration of daily oral methotrexate

• Transfusion of ABO incompatible blood components.

• Misplaced naso or oro gastric tubes

• Wrong gas administration

• Failure to monitor and respond to oxygen saturation

• Air embolism • Misidentification of patients

The Yorkshire Clinic reported one Never Event from 1st April 2016 - 31st March 2017.

The incident investigated and reported relates to a “never event” incident that regrettably occurred

on 2nd July 2016, where a patient was prepared and consented for left shoulder arthroscopy and

possible rotator cuff tendon repair, in the anaesthetic room a ‘wrong side block’ was injected in

error. Patient should have had an interscalene brachial plexus nerve block for post-operative

analgesia to the left shoulder but this was performed to the right shoulder.

The error was realised when positioning the patient in theatre as the patient was positioned for

surgery to the left shoulder. The anaesthetist realised he had blocked the wrong arm and

http://www.nrls.npsa.nhs.uk/resources/collections/never-events

http://www.nrls.npsa.nhs.uk/resources/collections/never-events


immediately informed the surgeon and the theatre team. The correct planned procedure was

carried out to the left side.

The investigation has confirmed that the root cause whilst all WHO Safety Checks were

documented (the ‘sign in’) and stated as occurred, this was not completed with focus from the

anaesthetist and the surgical site mark was not visible as it had been covered when the patients

arms were secured in preparation for the block. Ramsay Health Care Policy CN006 states that

“The sign in must include at least two people involved in the procedure”. In this instance that

should have been the ODP and Anaesthetist.

The investigation has also highlighted that the ‘Stop Before You Block’ campaign had not been

implemented at The Yorkshire Clinic.

The patient was kept in overnight for pain relief and nursing care and discharged home the

following day. The block to the right arm had worn off and he had full function back.

Action taken:

a. Procedures where left and right sides are being operated on will be listed as all ‘rights’

then all ‘lefts’ or vice versa to ensure continuity.

b. Consultant Surgeons will mark all surgical sites as close to the site as possible. The

mark must be an arrow which extends as close as possible to the site of intended

surgical incision, visible after the application of skin preparation and drapes.

c. The ODP and the anaesthetist will verbally complete the WHO surgical safety check

‘Sign in’ section with the patient as stated in Ramsay Health Care Policy CN006.

d. The surgical site mark will be visible to all theatre staff at all times in the anaesthetic

room.

e. Implement Ramsay Clinical Standard Operating Procedures No: CN006 SOP004, Title:

Stop Before You Block.

a. Before block needle insertion there will be a ‘Stop’ and check process consisting of:

• Correct procedure

• Verification of the surgical site mark visibility

• Correct site/side for block

• The anaesthetist and ODP will sign to confirm these checks have occurred

This never event investigation has now been closed via Bradford District Clinical

Commissioning Group (CCG) & the Strategic Executive Information System (STEIS).

2.2.2 Participation in Clinical Audit

During 1 April 2016 to 31st March 2017, 4 national clinical audits covered NHS services that The Yorkshire Clinic provides.

During that period The Yorkshire Clinic participated in 4 national clinical audits and did not participate in any National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

The national clinical audits that The Yorkshire Clinic participated in, and for which data collection was completed during 1st April 2016 to 31st March 2017, 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 Participation

(NA, No, Yes)

% cases

submitted

Comments

National Joint Registry (NJR) – Per

patient YES 87%

We will focus on improving the consent rate over 2017/2018 by nominating a key member of the clinical team who will continuously monitor compliance and take action if our processes are preventing the low consent rate.

National Confidential Enquiry into

Patient Outcome and Death

(NCEPOD)- Acute Pancreatitis: Treat

the Cause (2016)

NO NA We do not treat patients

with Acute Pancreatitis

JAG Census – Quarterly YES

All requirements met fully.

Elective surgery (National PROMs

Programme)

YES

Outcome snapshot provide on fig 1.

NHS Safety Thermometer YES 100%

All the above reports are discussed at the local clinical governance committee meetings to ensure no trends are developing and outliers are highlighted.

National Audits

A list of the national clinical audits we intend to undertake within the period 1st April 2017 to 31st March 2018 are as follows:

Name of audit / Clinical Outcome Review Programme

• National Joint Registry (NJR) – Per patient

• NHS Safety Thermometer

• Elective surgery (National PROMs Programme)

• JAG Census – Quarterly

• SSI – Surgical Site Surveillance – Quarterly

Local Audits The Yorkshire Clinic participates in the Ramsay Corporate Audit Programme (the schedule can be found in Appendix 3). The audit topic and schedule is set centrally by Ramsay Health Clinical Governance Committee to allow greater opportunity for benchmarking. Additionally The Yorkshire Clinic also carries out a number of local clinical audits all of which go through


the Clinical Governance Committee where actions are taken to improve the quality of the healthcare provided:

• Infection Prevention Audits: The Yorkshire Clinic has followed the Corporate Audit Programme throughout the year and results have shown improvement in hand hygiene where month on month we score >95% and Peripheral Venous catheter Care bundle where again we have achieved >95% against the audit criteria.

• Consent: Assesses the consent process in 2 stages. Stage one ensures that patients are provided with sufficient information to provide informed consent. Stage two confirms

that the patient is happy to proceed having had time to consider the information provided.

• Emergency Trolley Audit: To ensure that emergency equipment is ready for immediate use, a routine check of the defibrillator, oxygen and suction is undertaken daily. There is also a weekly audit of the content of the emergency trolley, this provides assurance that all emergency equipment is in date and there are sufficient numbers in each trolley as indicated by the Resuscitation Council (UK) 2015. These audit results are discussed and reviewed at the resuscitation committee meeting which is held quarterly. Our current hospital compliance to Emergency Trolley checks is 99.8%

• WHO – Surgical Safety Check Audit: Where any invasive procedures occur (Out-Patient department, Theatre, The Lodge, Radiology, Endoscopy, Angiography) we complete a monthly audit of WHO Surgical Safety Checks. The audit consists of review of the WHO checklist to ensure completion in full and also observational audit of the process to ensure safety checks occur as set in policy. The audit assesses that clinical staff are routinely checking that the correct patient, receives the correct surgery on the correct site, and the patient has been appropriately prepared and consented for the procedure planned. All departments scored >95% for WHO Surgical Safety Checks in March 2017

• Never Event Audit: Following our Never Event in July 2016 (Wrong Site Block) we

developed audits to assure our self that we said needed to change had changed in

practice.

The audits consisted of:

o Surgical Site Mark close to the surgical site. We audited Consultant practice to ensure they were marking surgical sites in line with standard operating policy CN006 SOP03 ‘Surgical site marking’.

o WHO Surgical ‘Safety Sign in’. We audited to ensure there was full team focus during the ‘Sign in’ phase of the WHO Surgical Safety Checks.

o Stop Before You Block practice in line with standard operating policy CN006 SOP04. We audited to ensure all aspects of the policy were being adhered to in practice.

• National Early Warning Scores (NEWS) audit – In 2016 we changed our scoring system for the assessment and response to patients acute illness. The National Early Warning Score (NEWS) system is used across the NHS, Ramsay Healthcare changed from there EWS (Early Warning Score) to the NEWS system. To ensure staff were using the new system as advocated during training we developed an audit tool to monitor practice. Our Current NEWS audit score is >95%.

2.2.3 Participation in Research

There were no patients recruited to participate during 2016/17 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 The Yorkshire Clinic income from 1st April 2016 to 31st March 2017 was conditional on achieving quality improvement and innovation goals. The goals were agreed between the Yorkshire Clinic and the lead Clinical Commissioning Group and forms part of a contract for the provision of NHS services. This is a national incentive scheme based on the Commissioning for Quality and Innovation framework.

Rationale for our choice:

1. Cancellations: Cancelled operations are wasteful in terms of both time and money. If cancelled by the provider then this is detrimental to the patient experience and if cancelled by the patient it is a waste of capacity and monies which could have been directed elsewhere.

2. Antibiotic Prescribing: Antimicrobial resistance has risen alarmingly over the last 40 years and inappropriate and overuse of antimicrobials is a key driver. Development of new classes of antimicrobials has dramatically reduced, whilst between 2010 and 2013 total antibiotic prescribing has increased by 6%, leaving the prospect of reduced treatment options and an increasing risk to standard surgical procedures.

3. Electronic transmission of outpatient clinic letters: In accordance with NHS England 16/17 Standard Contract, aim to transmit GP outpatient clinic letters via electronic transmission (2.2 Standard Contract)

Indicator Goal Description of indicator Indicator

Weighting CQUIN achieved

1 Evaluation of planned procedures Not Carried Out (Cancellations)

The provider will audit/review all patients who had a code of WA14Z (WA14A and WA14B) in 2015/16 and assess the reasons for the non-operation. A report will be prepared outlining the reasons for non-procedure and a process with timelines for reducing the number of patients who fall into this category whether it is due to patient’s cancelation or provider cancellation

25%

YES

2 Antibiotic prescribing Audit

The provider will review a sample of antibiotics prescribed by clinicians in the organisation and undertake audit to determine compliance with local prescribing guidance published on Leeds Health Pathways

50%

YES

3 Electronic transmission of outpatient clinic letters

To develop a robust process so that all initial outpatient clinic letters are sent via electronic transmission by 31 March 2017 to facilitate primary and secondary care providers become better integrated. In accordance with contract changes service condition 11.

25%

YES

The 2016/17 CQUINs were 100% achieved by The Yorkshire Clinic and the hospital has agreed the 2017/18 CQUINs to ensure continuous improvement in quality and innovation.

Full details of the 2017/18 incentive scheme are:


Indicator Goal Description of indicator Indicator Weighting

1 Improving the drug reconciliation triangle/3 way check to the current reconciliation process in line with NICE and NPSA Guidelines.

The Yorkshire Clinic are meeting the current standards legally required. The YC will be strengthening the medicine reconciliation triangle recommended by NICE/NPSA. The benefits of focusing and strengthening the reconciliation triangle into current process are 1. Further reduction in prescribing errors 2. Decrease in missed doses of medication 3. Improved quality of information available to clinicians 4. Decrease in hospital re-admissions due to harm from medication 5. Increased patient involvement in their own care.

50%

2 Re-alignment of the Yorkshire Clinic antibiotic formulary to reflect best practice and align to local NHS trusts.

The 2016/17 antimicrobial CQUIN highlighted gaps in practice around prescribing treatment and prophylaxis doses of antibiotics, therefore, this CQUIN will focus on aligning prescribing of treatment doses to Bradford teaching Hospitals Trust/Airedale General Hospital (BTHFT/AGH) formulary.

50%

2.2.5 Statements from the Care Quality Commission (CQC)

The Yorkshire Clinic is required to register with the Care Quality Commission and its current registration status on 31st March 2017 is registered without conditions. The hospital has not participated in any special reviews or investigations by the CQC during the reporting period.

The CQC carried out a 3 day inspection at The Yorkshire Clinic on 18th 19th and 20th October 2016. Using the new framework for inspecting the CQC assessed our services against five key questions:

• Are they Safe: You are protected from abuse and avoidable harm.

• Are they Caring: Your care, treatment and support achieves good outcomes, helps you to maintain quality of life and is based on the best available evidence.

• Are they Responsive: Services are organised so that they meet your needs.

• Are the Effective: your care, treatment and support achieves good outcomes, helps you to maintain quality of life and is based on the best available evidence.

• Are they Well Led: The leadership, management and governance of the organisation make sure it's providing high-quality care that's based around your individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

Our Rating by the CQC:

The CQC rated the Yorkshire Clinic ‘Good Overall’ for Surgery, Children & Young

People and Out-Patient & Diagnostic Imaging. In all the Five CQC Domains (Safe,

Effective, Responsive, Caring and Well Led) we achieved ‘Good’.


Safe Effective Caring Responsive Well Led Overall

Surgery

Children &

Young

People

Out- Patient

and Diagnostic

Imaging

Overall

Key Highlights from our Report:

• The service managed staffing effectively and services always had enough staff with

the appropriate skills, experience and training to keep patients safe and to meet their

care needs.

• Staff were encouraged to report incidents and we saw good sharing of learning

following incidents. Staff were aware of the two never events and subsequent

changes in practice.

• Mandatory training compliance levels were high and we observed good practice in

relation to infection prevention and control and medicines.

• Documentation was good and patient care and treatment was evidence based. There

were clear pathways of care and staff were able to recognise and respond to signs of

deteriorating health.

• Patients were involved in their care and treated with dignity and respect.

• Service provision was focused around the needs of the people using the hospital.

• The provider met national indicators for referral to treatment (RTT) waiting times.

• Staff spoke positively about their leaders and managers.

• The governance arrangements in place ensured that quality, performance and risks

were managed.

Outstanding practice, these were:

• The Pharmacy Department had undergone external benchmarking of their aseptic

department.

• The new Senior Children’s Nurse was building links to the local authority

safeguarding children’s board and had attended a recent link meeting.

• The Senior Children’s Nurse had started weekly two hour information and advice

safeguarding children ‘drop ins’. These had proved popular and provided a link

between local and national developments and staff.

There were no breaches of regulations. However, there were areas where the Provider

should make some improvements, even though a regulation had not been breached, to help

the service improve. These were:

• The provider should consider making designated areas more child focused.

• The provider should ensure that all staff receive an annual appraisal.

Good

Good

Good

Good

Good

Good

Good

Good

Not

rated

Good

Good

Good

Good

Not rated

Good

Good

Good

Good

Good

Good

Good

Good

Good

Good


• The provider should ensure best practice guidance is followed in relation to mental

capacity assessment and best interest’s decisions.

Where the CQC provided feedback on areas for improvement we have developed an action

plan which outlines what is required to make the improvements, who will complete the

actions and by when.

Summary of actions:

1. Unauthorised access to theatre: Action completed, all access is now via swipe card

by authorised personal only.

2. Physiotherapy outpatient department records were not always fully completed and we

saw examples of care plans, risk assessment scores and allergy records not always

being completed: Action completed, staff training and education. Monthly audit to

monitor compliance in place.

3. We lacked assurance over staffs understanding and training on mental capacity and

best interest decisions. Action on-going, staff training plan formulated to ensure all

staff have knowledge of mental capacity and best interest decisions and what to do

when presented with these in practice.

4. We were provided with several figures in relation to staff appraisals. Appraisal figures

for theatre staff were 60%. Action on-going. All departments have an appraisal plan

which will ensure 100% compliance in all areas by July 2017.

5. Some patients told us that they felt that their dignity was not always maintained in the

radiology waiting area. Action complete, patients do not sit in hospital gowns in the

radiology waiting area. New facilities/process in place to maintain patient privacy and

dignity.

2.2.6 Data Quality

The Yorkshire Clinic will be taking the following actions to improve data quality.

Good quality information underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. Improving data quality, which includes the quality of ethnicity and other equality data, will thus improve patient care and improve value for money. On induction our staff are trained on how to obtain and input data correctly onto our electronic systems and also how to handle it confidentially, staff are monitored on correct data capture via internal reports and data quality training is updated regularly throughout the hospital.

At The Yorkshire Clinic data quality is one of our highest priorities to ensure we produce clean and accurate electronic data which we can use to monitor and improve our quality of care and service. Throughout the year we have updated and strengthened our processes to capture data in a timely manner and to audit data prior to submission. We are constantly looking to improve data capture and reporting processes supported by a dedicated corporate quality team.

NHS Number and General Medical Practice Code Validity

The Ramsay Group submitted records during 2016/17 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: The patient’s valid NHS number:

• 99.97% for admitted patient care;


• 99.96% for outpatient care; and

• Accident and emergency care N/A (as not undertaken at Ramsay hospitals). The General Medical Practice Code:

• 100% for admitted patient care;

• 99.99% for outpatient care; and

• Accident and emergency care N/A (as not undertaken at Ramsay hospitals).

Information Governance Toolkit Attainment Levels Ramsay overall information governance toolkit score for 2016 /17 is 82% and is green

(satisfactory)

This information is publicly available on the DH Information Governance Toolkit website at: https://www.igt.hscic.gov.uk To comply with Information Governance Requirement 505 for internal clinical coding audit of

NHS coded data, HSCIC recommend a score of at least a level 2 in all 4 areas for diagnosis

and procedural coding. The table below shows the percentage accuracy scores as targets:

Required attainment level For IG 505

Level 2 Level 3

Primary diagnosis > 90% >95%

Secondary diagnosis >80% >90%

Primary procedure >90% >95%

Secondary procedure >80% >90%

Clinical Code Error Rate

The Yorkshire Clinic was last audited in May 2016 evidencing an overall level 3 and a score

rate for the following:

As evidenced in the table above; The Yorkshire Clinic achieved above average scores for

clinical coding error rate.

Hospital Site Next Audit Date

Primary Diagnosis

Secondary Diagnosis

Primary Procedure

Secondary Procedure

Yorkshire Clinic Aug 17 98.33% 97.54% 98.31% 100%

https://www.igt.hscic.gov.uk/


2.2.7 Stakeholders’ Views on 2016/17 Quality Account


Part 3: Review of quality performance 2016/2017

Statements of quality delivery

Matron, Jan Matin

Review of quality performance 1st April 2016 - 31st March 2017

Introduction

“This publication marks the eighth successive year since the first edition of Ramsay

Quality Accounts. As we have previously done through each year, we continue to

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.

I am pleased to say that whilst the numbers of patients choosing Ramsay for their

care continues to increase, quality continues to also improve as demonstrated by

improved clinical outcomes and measures.

We listen where concerns or suggestions have been raised and, in this account, we

have set out our track record as well as our plan for more improvements in the

coming year. This is a discipline we vigorously support, always driving this cycle of

continuous improvement in our hospitals and addressing public concern about

standards in healthcare, be these about our commitments to providing

compassionate patient care, assurance about patient privacy and dignity, hospital

safety and good outcomes of treatment. We believe in being open and honest where

outcomes and experience fail to meet patient expectation so we take action, learn,

improve and implement the change and deliver great care and optimum experience

for our patients.”

Vivienne Heckford

Director of Clinical Services



Ramsay Clinical Governance Framework 2017

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 for example 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

Mortality: Period Best Worst Average

Period Yorkshire

Oct 14 - Sep 15 RKE 0.652 RVW 1.18 Average 1 2014/15 NVC20 0.0058782

Oct 15 - Sep 16 RKE 0.689 RLQ 1.16 Average 1 2015/16 NVC20 0

Independent data is not included by the HSCIC. We have pulled unexpected

mortalities from RiskMan for comparison.


In addition to providing surgical care and treatment, The Yorkshire Clinic provides care and

treatment for patients with long term chronic medical conditions and end stage cancer under

the care of Consultant Oncologists and Physicians. Most of these patients choose to be

cared for at the hospital on an end of life pathway during the end stage of their disease

process. The table above explains the mortality rate that has occurred at The Yorkshire

Clinic in the last year. The Yorkshire Clinic Mortality rate is below the national average.

During the period of 31st March 2016 - 1st April 2017 we had one expected patient death.

Any patient death is reviewed by our clinical governance committee to ensure

analysis and assurance the patient pathway was managed in line with Ramsay

Policies and National regulations.

0

1

2

14/15 15/16 16/17

Mortality


0.00%

0.00%

0.00%

0.01%

0.01%

14/15 15/16 16/17

Unexpected Deaths



PROMS (Patient reported outcome measures)

Fig.1 Adjusted Health Gain

Data available at http://content.digital.nhs.uk/proms The HSCIC data for PROMS includes private providers so all of the data table comes from this source. Most recent data in March was used: Apr 15 – Mar 16 and Apr 16 – Sep 16 Measure is the Adjusted Health Gain (EQ-5D) - Hernia Measure is the Adjusted Health Gain (Primary Oxford Hip Score) - Hips and Knees

PROMS: Period Best Worst Average

Period Yorkshire

Hips Apr15 - Mar16

RYJ 24.973 RBK 16.892 Eng 21.617 Apr15 - Mar16

NVC20 20.335

Apr16 - Sep16

NTPH1 25.204 RFS 17.838 Eng 22.018 Apr16 - Sep16

NVC20 20.14

Outlined in the table above are the patient reported outcomes for The Yorkshire Clinic. This is compared to the national best, worst and average scores from the UK.

The Yorkshire Clinic participates in the Department of Health PROM’s survey for hip, knee and hernia surgery for NHS and private patients. PROMs indicate a patient’s health status or health-related quality of life from the patient’s perspective, based on information gathered from a questionnaire that patients complete before and after surgery. PROMs offer an important means of capturing the extent of patients’ improvement in health following ill health or injury. The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s patient reported outcome measures scores for:- (i) groin hernia surgery, (ii) hip replacement surgery, and (iii) knee replacement surgery, We monitor our outcomes by reviewing the PROMS data at our Clinical Governance Committee. Our current focus is to:

• Increase the number of returns for both our NHS and Private patients as to enable objective analysis and comparison to other hospitals we need a larger number of returns.


Period Yorkshire

Knees Apr15 - Mar16

NTPH1 19.920 RQX 11.960 Eng 16.368 Apr15 - Mar16

NVC20 16.177

Apr16 - Sep16

NTPH1 21.349 RK5 12.647 Eng 16.877 Apr16 - Sep16

NVC20 16.42


Period Yorkshire

Hernia Apr15 - Mar16

NT438 0.157 RVW 0.021 Eng 0.088 Apr15 - Mar16

NVC20 0.114

Apr16 - Sep16

RJR 0.162 RNA 0.0162 Eng 0.089 Apr16 - Sep16

NVC20 0.102

http://content.digital.nhs.uk/proms

http://content.digital.nhs.uk/catalogue/PUB23060

http://content.digital.nhs.uk/catalogue/PUB23061


Readmissions: Rate per 100 admissions:

Readmissions: Period Best Worst Average

Period Yorkshire

2010/11 Multiple 0.0 5P5 22.76 Eng 11.43 2010/11 NVC20 4.64

2011/12 Multiple 0.0 5NL 41.65 Eng 11.45 2011/12 NVC20 7.69

This is the most current data for 2011/12 and 2010/11 by: https://indicators.ic.nhs.uk/download/NCHOD/Data/03N_523ISP4ADF_12_V1_D.xls

Monitoring rates of readmission to hospital is another valuable measure of clinical

effectiveness and outcomes. As with return to theatre, any emerging trend identified with a

specific surgical operation or surgical team may identify contributory factors to be addressed.

As evidenced in the table above The Yorkshire Clinic can demonstrate readmission rates

have reduced in 2016/2017 compared to 2015/2016 this is due to sound clinical practice and

governance which ensures staff have the skill and knowledge to provide care to patients in

their differing state of recovery and ensuring patients are not discharged home too early after

treatment. Improvements in patient education and communication has also played a key to

the decline as we start discharge communication early in the patient pathway and ensure

they are fully informed of what they can expect at every stage of their recovery. Continuity of

care after patients are discharged from hospital has been critical in ensuring that the patient’s

treatment plan is continued at home, and to ensuring that patients have appropriate support

at the time of discharge.

Responsiveness to personnel needs:

Responsiveness: Period Best Worst Average

Period Yorkshire

to personal 2012/13 RPC 88.2 RJ6 68.0 Eng 76.5 2013/14 NVC20 92.7

needs 2013/14 RPY 87.0 RJ6 67.1 Eng 76.9 2014/15 NVC20 93.2

This is the most current data held by:

https://indicators.ic.nhs.uk/download/Outcomes%20Framework/Data/NHSOF_4b_I00683_D_V8.xls

The table above shows The Yorkshire Clinic is above National average is responding to patient’s personal needs.

Feedback from patients regarding their experience at The Yorkshire Clinic is encouraged and is essential to inform our staff how care can be enhanced or adjusted to meet individual patient satisfaction. All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour – letters and cards are displayed for staff to see on our communication boards. We have monthly customer care champions who are identified through feedback received form our patients.

We have a ‘Customer Focus Group’ who review all feedback provided by our patients this includes complaints, negative comments and any suggestions for improvement. This group look for trends and themes for action to ensure we are continuously improve our care and services from feedback provided by our customers.

All our staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care or service delivery. Every complaint received is given immediate attention of the General Manager and Matron on the day it is received, following which a thorough investigation is commenced into the concerns raised as per Ramsay Complaints Policy. Our staff as part of the ‘customer care’ training receive training on complaints

https://indicators.ic.nhs.uk/download/NCHOD/Data/03N_523ISP4ADF_12_V1_D.xls

https://indicators.ic.nhs.uk/download/Outcomes%20Framework/Data/NHSOF_4b_I00683_D_V8.xls


management to ensure our patients feel listened to and that we take any feedback seriously and will use it to improve our services and care delivery.

We encourage feedback from our patients so we can respond to their needs; feedback is encouraged through the following routes:

• Patient satisfaction surveys

• We value your opinion questionnaire leaflet

• Direct verbal feedback to Ramsay staff.

• Internal Ramsay audit /inspection processes.

• CQC inspection feedback.

• Written feedback via letters/emails/complaints

• Patient focus groups

• PROMs surveys

• Social media

• NHS Choices

• Annual PLACE patient audit

• Daily ward rounds conducted by senior ward nurses.

Venous thromboembolism (VTE)

VTE Assessment:

Period Best Worst Average

Period Yorkshire

16/17 Q2 Several 100% NV302 0.0% Eng 95.5% 15/16 Q2 NVC20 97.4%

16/17 Q3 Several 100% NT490 65.9% Eng 95.6% 15/16 Q3 NVC20 97.2%

VTE Assessment (https://www.england.nhs.uk/statistics/statistical-work-areas/vte/)

The value included is the from the "Percentage of admitted patients risk-assessed for VTE" column

The Yorkshire Clinic carry out a VTE risk assessment on all admitted patients as per Ramsay policy which is based upon the National Institute for Clinical Excellence (NICE) Guidance 2010. The National Institute for Clinical Excellence (NICE, 2010) recommends that all patients

should be assessed for risk of developing thrombosis (blood clots) on a regular basis, as

follows:

• On admission to hospital

• 24 hours after admission to hospital

• Whenever their medical condition changes

• Before discharge

• every patient should receive information on how to continue preventative measures at

home.

The Yorkshire Clinic VTE risk assessment document will indicate whether a particular patient

is at high risk of developing blood clots. This may be as a result of their own individual risk

factors (their age, medical history etc.) as well as their reason for being admitted to a surgical

ward (e.g. a condition which will result in them being bed-bound).

As evidenced in the table above the Yorkshire Clinic demonstrate that we are significantly above the national average for VTE risk assessment completion, this reflects our commitment to patient safety and risk management. To ensure we continue to achieve a high score we:

• Undertake audits to monitor compliance to VTE management.

https://www.england.nhs.uk/statistics/statistical-work-areas/vte/


• Train all our clinical staff on how to complete a risk assessment and actions to take. • Report any VTE events (Deep Vein Thrombosis, Pulmonary embolism) to ensure a

root cause can be identified and action take to improve, learn from these events.

Clostridium Difficile Infection

Rate per 100,000 bed days comes from https://www.gov.uk/government/statistics/clostridium-difficile-

infection-annual-data (this is the most current data available)

Independent data is not included so our own data is used for comparison against the same time frame (C Diff

pulled from RiskMan)

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period. The above table demonstrates our high standards of infection prevention and control processes as there have been no cases of Clostridium Difficile Infection Reported. Healthcare associated infections (HCAI) are acquired as a result of healthcare intervention. High standards of Infection Prevention and Control practice minimise the risk of occurrence of HCAIs. To ensure we maintain this score, and so the quality of its services, The Yorkshire Clinic:

• Have a Local IPC Committee which is chaired by a Consultant Microbiologist and consists of representatives from all areas of the hospital. The Committee meets quarterly to oversee implementation of Corporate policies, National guidance and review clinical audit & practice.

• Ensure all staff undertake mandatory infection prevention and control (IPC) training annually.

• Complete clinical audits identifying trends which are then actioned.

• Have appointed an Infection Control Lead Nurse.

• Have a whole-system approach to infection prevention and control with clear structures, roles and responsibilities aimed at reducing lapses in care and harm from avoidable infection

• Have through effective systems of education, audit and surveillance developed a culture of continuous improvement to enhance patient safety, compliance with infection prevention and control policies and guidelines to ensure good infection prevention practice.

• Are actively working on ways to adhere to antimicrobial stewardship and ensure antimicrobial prescribing is compliant with the Ramsay formulary.

Incident Rates and Patient Safety

SUIs: Period Best Worst Average

Period Yorkshire

(Severity 1 only)

Apr 15 - Sep 15

Several 0 RY3 2.39 Eng 0.21 Apr 15 - Sep 15

NVC20 0.00

Oct 15 - Several 0 RY6 4.45 Eng 0.21 Oct 15 - NVC20 0.01

C. Diff rate:

Period Best Worst Average

Period Yorkshire

per 100,000

2014/15 Several 0 RPY 62.2 Eng 15.1 2012/13 NVC20 0.0

bed days 2015/16 Several 0 RPY 66.0 Eng 14.9 2013/14 NVC20 0.0

https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data

https://www.gov.uk/government/statistics/clostridium-difficile-infection-annual-data


Mar 16 Mar 16

No independent sector data, pulled from RM (Overall Sev 1) Acute Non-Specialist Data From NRLS, England

Table 1

Table 2

Table 3

The above table (table 1) show The Yorkshire clinic is below the national average in number

of Serious Untoward Incidents (SUIs) reported and there is a decline in 2016-2017 in the

number of SUIs. This is a reflection of the work carried out to heighten patient safety

0.00%

0.05%

0.10%

0.15%

14/15 15/16 16/17

SUIs


0

100

200

300

14/15 15/16 16/17

Clinical Incidents


0.00%

0.50%

1.00%

1.50%

2.00%

14/15 15/16 16/17

All Incidents



especially during invasive procedures. Key Mandatory checks for example the WHO Safe

Surgery Checks have been a key focus in 2016-2017. The introduction of the National Safety

Standards for Invasive Procedures (NatSSIPs) has also been pivotal to the reduction of

patient safety incidents. We have introduced ‘List safety Officers’ who are key identified

members of any team where invasive procedures occur, their role is to ensure ‘Patient

Safety’ by enforcing systems and processes are followed in line with best practice, policy and

national guidance.

Table 2 and 3 shows an increase in reported incidents inc clinical incidents. This increase

has been following focused training for all staff on the importance of reporting incidents. The

senior management team have delivered a number of staff forums where staff have been

encouraged to report incidents, share learning and learn from mistakes. A ‘no blame culture’

is encouraged and staff are informed that they we are committed to learn from mistakes and

share learning.

The Yorkshire Clinic strives to report any incidents or near misses in real time through an

electronic incident reporting tool called “Riskman”. Every incident is promptly reviewed by

Matron and the department manager. All our incidents are fully investigated; actions are

formulated to enable learning and changes in practice.

All incidents are categorised dependent on severity. The National Patient Safety Agency

(NPSA) root cause analysis investigation tool is used complete a root cause analysis to

investigate serious incidents, by completing a root cause analysis we identify the prime

reason(s) why an incident occurred and then we take action which will either prevent, or

reduce the chances of a similar type of incident from happening in similar circumstances in

the future.

All incidents are analysed and discussed at the Clinical Governance Committee, the

committee review trends and themes and ensure appropriate action has been taken to

reduce or prevent the incident re-occurring. All incidents are also discussed at departmental

team meetings to enable shared learning and to ensure front line staff are fully aware of what

incidents have occurred and action taken. We believe it is through shared lessons learnt form

incidents we can improve patient safety and reduce/stop serious incidents from re-occurring.

Other National reporting mechanisms e.g. MHRA; CQC; NHS England CAS alerts and local

NHS networks are used via the Ramsay CAS alert process to share information with frontline

staff as and when this is updated. It is standard practice for Ramsay hospital sites to share

any incidents and lessons learnt regionally and nationally through Committee meetings and

local and national Matrons meetings in addition to our local NHS Trusts and commissioners.

Friends and Family Test

F&F Test: Period Best Worst Average

Period Yorkshire

Jan-17 Several 100% RJ731 61.1% Eng 95.7% Jan-17 NVC20 98.8%

Feb-17 Several 100% NT3X3 72.7% Eng 95.8% Feb-17 NVC20 99.6%

F&F Test (https://www.england.nhs.uk/ourwork/pe/fft/friends-and-family-test-data/)

The trusts score from a single question survey which asks patients whether they would recommend the NHS

service they have received to friends and family who need similar treatment or care.

It is initially for providers of NHS funded acute services for inpatients (including independent sector organisations

that provide acute NHS services)


A NHS-wide ‘friends and family’ test to improve patient care and identify the best performing hospitals in England was announced in 2012 by the Prime Minister.

All patients at The Yorkshire Clinic are routinely invited to take part in this anonymous survey. By completing a simple questionnaire asking whether they would recommend our hospital to their family and friends. Scores are published on the NHS Choices Website www.gov.uk

Alongside providing clinical excellence and safe care, patient experience is the key measure of quality. The Yorkshire Clinic will use the information received from our patients in this survey in order to improve the service we offer.

We recognise that we have scored above the national average due to robust processes in place however; the Yorkshire Clinic has taken the following actions to continue to score highly, and so maintain the quality of its services, by:

• Continuing to raise awareness of staff of the importance of patient feedback by highlighting results through Customer Focus Group, staff meetings and Customer Care Excellence training

• Reviewing the overall feedback from all users and developing action plans to address issues highlighted

• Displaying on communication boards our recent “Friends and Family” results and action we have identified that will enhance quality and patient experience.

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.

0

5

10

15

20

14/15 15/16 16/17

Readmissions


http://www.gov.uk/


0

5

10

15

20

25

14/15 15/16 16/17

Transfers


0

5

10

15

20

25

30

14/15 15/16 16/17

Hospital Acquired Infections


0

1

2

14/15 15/16 16/17

Serious Complaints



3.2.1 Infection prevention and control

The Yorkshire Clinic has a low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 4 years.

We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to maintain low rates of infection 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.

The graph below shows our year on year decline of infections reported.

0

5

10

15

20

25

14/15 15/16 16/17

SUIs


0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

2014/15 2015/16 2016/17

Infe

ctio

n R

ates

(p

erce

nta

ge o

f A

dm

issi

osn

s)


Infection Rates


Programmes and activities within our hospital include:

The Yorkshire Clinic understands that Infection Control is a core part of an effective risk management programme, aiming to improve the quality of patient care and the occupational health of staff, in addition to the clinical need to prevent Healthcare Associated Infections (HCAI), and protect patients from harm.

The Yorkshire Clinic infection control processes are coordinated and led by an experienced Registered Nurse. The Yorkshire Clinic Infection Prevention & Control Committee comprises of Consultant Microbiologist, Infection Control Lead; Hospital Matron; Theatre Manager; Ward Manager; Hospital Engineer; Pharmacy Manager and Link Nurses from Theatre, Wards, Outpatients and Endoscopy. Meetings are held quarterly and provide the hospital with infection prevention advice and guidance in conjunction with Ramsay Infection Prevention & Control Policies and Procedures and National Guidance. All staff undertake mandatory annual e-learning and practical training sessions for Infection Prevention and our Consultant Microbiologist also provides bi-annual in house training. A comprehensive infection control audit programme has been maintained throughout 2016/2017.

We have an Infection Prevention Annual plan and this outlines our strategy and vision for the year.

Our 2016/2017 Annual plan focused on:

• Hand hygiene (posters and leaflets visible, encouraging visitors and patients to use

facilities and challenge staff. Review hand gel supplier, public signage (Change to GOJO)

• Focus on Surgical Site Care bundle (NICE) guidelines for the prevention and

management of SSI in 2008.

• Compliance to Surveillance Policy (IPC 14) monitor all hip and knee arthroplasty patients

for 30 days in line with PHE Surveillance Programme.

• Antimicrobial prescribing in accordance with National formulary through accountable

Antimicrobial Stewardship:

• Mandatory ANTT training and Competency assessment.

• Every department to have a cleaning schedule which:

- Lists all equipment

- Cleaning standard

- Responsibility

- Frequency

Infection Prevention and Control Audits undertaken during 2016/17 achieved average scores of: -

Audit Audit Score

Hand Hygiene 99%

Peripheral Venous Catheter Care Bundle 96%

Urinary Catheter Care Bundle 96%

Surgical Site Infection 98%

Environment 98%

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 the Yorkshire Clinic,


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. During 2016/17 The Yorkshire Clinic took part in Patient Led Assessment of the Care Environment (PLACE) which builds on the foundation of The Patient Environment Action Team (PEAT) assessments, with two main differences:

• Patients make up at least 50% of the assessment team giving patients a much stronger voice.

• Focus is on improvement with hospitals required to report publicly and say how they plan to improve.

The Health & Social Care Information Centre results for our annual PLACE Audit undertaken

in April 2016, achieved scores in the following areas:

Assessment Area Site Score National Average score

Cleanliness

98.74% 98.06%

Food

91.77% 88.24%

Organisation Food

91.32% 87.01%

Ward Food

92.24% 88.96%

Privacy, Dignity and Wellbeing

82.35% 84.16%

Condition, Appearance And Maintenance

92.91% 93.37%

Dementia

77.58% 75.28%

Disability

73,02% 78.84%

The chart identified that we were above the national average for all scores except Privacy,

Dignity and Wellbeing, Disability and Condition, Appearance and Maintenance.

Our Patient Led Assessment of the Care Environment (PLACE) audit was conducted in April 2016 where we received positive feedback from our patient assessors.

We have taken the following actions to improve on the scores above:

Action taken

External Areas:

• Gutters Cleaned outside the hospital

• Road markings renewed to indicate traffic flow

Ward Cleanliness:

• High surface- Dust: Cleaning schedule to ensure daily dusting

• Watermark on ceiling tiles- all tiles changed immediately where mark identified.

OPD:


Action taken

• Sinks and basins- sealant all sealant renewed.

• Skirting boards- dust- daily cleaning and records in cleaning manual.

• Waste Bins- Dirt inside bin frame- rust- all rusty bins replaced.

• Chipped skirting boards- ‘Handy man’ employed to keep up with Maintenance work.

Food:

• Menu now available in other languages and formats.

• Soup cold on arrival- All food temperature checked prior to delivery.

Communal Areas:

• Light fittings need cleaning throughout the hospital

• Internal decoration: Main reception- Some marks/chipped skirting boards.

• The mammography suite has been re decorated.

• The physiotherapy department has recently been re-painted

Monthly programme in place for cleaning light fittings.

Painter/decorator recruited to maintain internal decoration, chipped wood, and skirting boards.

Dementia section

• All hospital Signs reviewed/changed to ensure patients and visitors can easily see location of

areas and toilets.

• Large face clocks displayed receptions and out-patient areas.

• Doors to exists are now clearly marked

Disability:

Hearing loop system available at reception desks.

Privacy, Dignity and Wellbeing:

• The MRI suite has been fitted with new privacy curtains and tracking.

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.

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, Drugs, Medical device recalls and new and revised policies are cascaded in this way to our General Manager and Matron which ensures we keep up to date with all safety issues. All relevant CAS alerts which require action are reviewed and discussed through Health and Safety Committee, Clinical Governance and Medical Advisory Committee meetings and response actions monitored.

The Yorkshire Clinic have an occupational health nurse on site who is linked to the wellbeing programme ensuring staff are supported and robust reporting of incidents. All clinical staff complete skin surveillance assessments this is directly accessed through the Riskman reporting system, and where any staff have any ‘issues’ they are supported through our Well-being team. All staff complete a health screening questionnaire before employment commencement, through this they are supported to ensure they are safe and fully equipped to undertake there role.


A comprehensive Health, Safety and Facilities audit was carried out at The Yorkshire Clinic by the Ramsay group Health & Safety Manager in January 2017. This audit returned a score of 93%. This is an improvement from the 2016 score of 91%.

In July 2015 The Yorkshire Clinic were successfully recertified for compliance with Information security ISO 27001 following an in-depth audit. ISO27001 is the international standard describing best practice for Information Security Management. There were some minor non-conformity and several observations for improvements including further increasing of awareness amongst staff and changes to the layout and security of some of the internal rooms.

3.2.3 Clinical Effectiveness

The Yorkshire Clinic has a Clinical Governance Team and Committee that meet quarterly throughout 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, medical advisory committees and our commissioner quality leads to ensure results are visible and tied into actions required by the organisation as a whole.

3.2.4 Return to Theatre

The Yorkshire Clinic is treating significantly higher numbers of patients year on year as our

services grow. The majority of our patients undergo planned surgical procedures; however

as with all surgery there are recognised risks and complications, occasionally requiring

further surgery. It is therefore important to monitor the number of patients that require a

return to theatre to establish whether this was avoidable and whether there are any learning

to adopt. The value of the measurement is to detect trends that emerge in relation to a

specific operation or specific surgical team. As demonstrated in the graph below, The

Yorkshire Clinic’s rate of return to theatre has increased over the last year this can be

attributed to:

1. Improved reporting: We have actively encouraged staff to report any variances in

patient pathway which includes returns to theatre. In the past recording was not

robust.

2. Opening of HDU /Complex Procedures: We provided care for level 2 patients

which natuarllly increased the complexity of procedures we underttok, this then inturn

increased the risk of complaications.


3.3 Patient experience

All feedback from patients regarding their experiences with Ramsay Health Care is welcomed and informs our service development in various ways dependent on the type of experience (both positive and negative).

The Yorkshire Clinic established a pathway to record the government Friends and Family initiative within 2016/17. This has been embedded and the results have been very positive. A sample of January 2017, results are outlined below indicating that The Yorkshire clinic achieved a high test score of the North of England hospitals

(NHS England, January 2017)

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

2014/15 2015/16 2016/17

Ret

rnn

to

Th

eatr

e(P

erce

nta

ge o

f A

dm

issi

osn

s)


Return to Theatre Score


Friends and Family Test Score

The above table shows The Yorkshire Clinics score of patients who would recommend the Yorkshire Clinic to friends and family against the other local providers. (January 2017)

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 fed back 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 the Care Quality Commission occurs as required in line with Ramsay policy.

Feedback regarding the patient’s experience is encouraged in various ways via:

• Continuous patient satisfaction feedback via a web based invitation as our patients register.

• Hot alerts are received within 48hrs of a patient making a comment on their web survey directly to the hospital, initiating immediate attention and response to make improvements where necessary

• Yearly CQC patient surveys

• Government Friends and family questions asked on patient discharge

• A Ramsay questionnaire ‘We value your opinion’ is freely available throughout the hospital.

• 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 – We intend to instigate a patient focus group in June 2016

• PROMs surveys

• Care pathways – patient are encouraged to read and participate in their plan of care which supports additional patient feedback.

3.4 Patient Satisfaction Surveys

Our Web based patient satisfaction surveys initiated at patient registration 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 48hours of receiving them so that a response can be made to the patient as soon as possible.

The graph below shows our Patient Satisfaction rate has increased from the previous year; this reflects our continued efforts to improve our patient’s experience.


3.5 Hospital Case Study

Pathway for patients undergoing ‘Pain injection’ Procedures.

The Yorkshire Clinic offers a Pain Management Service delivered by our Consultant Anaesthetists, for the last 3 years the patient pathway has been very fragmented and patients were admitted to ward one where the admission process was completed and here they were prepared for their procedure. They were then escorted back to the ground floor where the angiography suite is situated. Our patients through the Patient Focus Group, Friends and Family feedback and Ramsay Patient satisfaction survey feedback expressed that the pathway was disjointed. They felt walking past patient bedrooms from ward one to the ground floor in the hospital was ‘undignified’, they also felt they were moved from one room to another before reaching the procedure room. Previous pathway:

• Arrival at Reception. (Ground Floor)

• Walk up to Ward One waiting room. (First Floor)

• Admission in consultation room Ward One. (First Floor)

• Changing facilities Ward One Ambulatory Unit. (First Floor)

• Walk down to ground floor outside procedure room.

• Procedure in Angiography Suite. (Ground Floor)

• Discharge home from Angiography Suite.

How our patients felt:

• Exposed walking down in a hospital gown.

• Physically uncomfortable having to walk a distance.

• Privacy and dignity compromised. We listened to our patients and changed the pathway; we created a new admissions area

and changing facilities on the ground floor adjacent to the Angiography Lab. Our changing

facilities are segregated (Male and Female). Patient Privacy and Dignity is at the heart of

this new pathway.

93.1 93.9

0

20

40

60

80

100

2014/15 2015/16

Sati

sfac

tio

n S

core

s


Satisfaction ScoresNHS/Private Patients


Our New pathway: All on the Ground floor

• Arrival at reception.

• Walk to the admission lounge.

• Admitted by angiography staff in new admission room.

• Prepared for procedure in adjacent rooms which is divided into male and female.

• Escorted to the procedure room.

• Discharge home.


Appendix 1 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.

Audit Programme v9.0 2016/17 Hospital Name: Orwell Implemented: July 2016

Authors: S. Harvey / A. Hemming-Allen / N. Carre For review: June 2017

Use arrow symbol to locate required audit

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

Medical Records Med Rec VTEDet Pt Med Rec VTE N & H Med Rec VTE Det Pt Med Rec VTE N & H

ConsentConsent Consent Consent Consent

Pre admission / DischargePA & Dis PA & Dis

Green 100%

Care Pathways and Variance

Tracking CP & VT CP & VT

Cool

Amber 90 - 99%

Controlled DrugsControlled

Drugs

Controlled

Drugs

Controlled

Drugs

Controlled

DrugsAmber 80 - 89%

PrescribingPrescribing Prescribing

Hot

Amber70 - 79%

Medicines Management Medicines

Management

Medicines

ManagementRed 69% and under

Surgical Safety for Invasive

ProceduresSurgical

Safety

Surgical

Safety

Surgical

Safety

Surgical

Safety

Infection Prevention and

Control*Isolation Hand

hygiene PVCCB UCCB

Hand

hygiene SSI CVCCB

Hand

hygiene PVCCB UCCB

Hand

hygiene SSI

IPC - Environmental / Hand

Hygiene ActionEnviron

Monthly

Hand

hygiene Environ

Monthly

Hand

hygiene

Monthly

Hand

hygiene Environ

Monthly

Hand

hygiene

Monthly

Hand

hygiene Environ

Monthly

Hand

hygiene

TransfusionCompliance

Allogeneic

Traceability

Auto logous

Traceability

Copyright © 2014 Ramsay Health Care UK

UCCB = Urinary Catheter Care Bundle

Det Pt = Deteriorating Patient

N&H = Nutrition and Hydration

VTE = Venous Thromboembolism

MM = medicines Management

Traffic light score

*Key:

CVCCB = Central Venous Catheter Care Bundle

SSI = Surgical Site Infection

PVCCB = Peripheral Venous Cannula Care Bundle


The Yorkshire Clinic Hospital


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:

Hospital phone number

01274 550600

www.theyorkshireclinic.co.uk

http://www.theyorkshireclinic.co.uk/

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