OaklandsHospital

Quality Account

2013/14

Quality Accounts 2013/14

Page 1 of 35

Contents

Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1 / Statement From The General Manager
1.2 / Hospital Accountability Statement
PART 2
2.1 / Priorities for Improvement
2.1.1 / Review of Clinical Priorities 2013/14(looking back)
2.1.2 / Clinical Priorities for 2014/15(looking forward)
2.2 / Mandatory Statements Relating To The Quality Of NHS Services Provided
2.2.1 / Review of Services
2.2.2 / Participation in Clinical Audit
2.2.3 / Participation in Research
2.2.4 / Goals Agreed with Commissioners
2.2.5 / Statement from the Care Quality Commission
2.2.6 / Statement on Data Quality
2.2.7 / Stakeholders Views on 2013/14 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1 / The Core Quality Account Indicators
3.2 / Patient Safety
3.3 / Clinical Effectiveness
3.4 / Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits

Welcome to Ramsay Health Care UK

Oaklands Hospital is part of Ramsay Health Care

The Ramsay Health Care Group, was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31acute hospitals.

We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver thousands of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Groups, NHS Trusts and NHS referral management and triage services.

“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high quality patient care is our number one goal. This relies not only on excellent medical and clinical leadership in our hospitals but also upon an organisation-wide commitment to drive year on year improvement in patient satisfaction and clinical outcomes.

Delivering clinical excellence depends on everyone in the organisation. It is not about reliance on one person or a small group of people to be responsible and accountable for our performance. It is essential that we establish an organisational culture that puts the patient at the centre of everything we do and as a long standing and major provider of healthcare services across the world, Ramsay has a very strong track record as a safe and responsible healthcare provider and we are proud to share our results.

Across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends. We value our people and with every year we set our targets higher, working on every aspect of our service to bring a continuing stream of improvements into our facilities and services.”

(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)

Introduction to our Quality Account

This Quality Account is Oaklands Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience. It also demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patients’ 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, developed by our Corporate Office, summarised and reviewed quality activities across every hospital within Ramsay Health Care UK. It was recognised that this didn’t provide enough in-depth information for the public and for 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

1.1Statement on Quality from the General Manager

This is the fourth Quality Account to be submitted by Oaklands Hospital and has been produced to demonstrate our commitment to measuring all feedback from patients about their experience, clinical treatment and clinical outcomes. This allows us to continually review, reflect on and improve the patient’s journey.

Patient safety is our highest priority and our robust recruitment processes and training programmes ensure that staff are competent and fully trained in all aspects of service provision.

Weachieve consistently high patient satisfaction scores and, by studying results throughout the year, we constantly seek ways to further improve the patient experience.

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.

As General Manager of Oaklands Hospital, I am passionate about ensuring that high quality patient care is our number one priority. Our Quality Account is an accurate representation of our performance and our ongoing initiatives to continuously improve the quality of our services.

Helen Rocca, General Manager

Oaklands Hospital

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.

Helen Rocca,General Manager

Oaklands Hospital, Ramsay Health Care UK

This report has been reviewed and approved by:

Mr Henry Maxwell, Consultant Surgeon and Chair Medical Advisory Committee, Oaklands Hospital

Stefan Andrejczuk, Regional Director, Ramsay Health Care

Welcome to Oaklands Hospital

OaklandsHospital is one of Greater Manchester's leading private hospitals with a reputation for delivering high quality healthcare treatments and services. Located in Salford, the hospital is close to the A580 and the M602. The hospital opened in 1990 and currently has 15 single rooms all with en- suite facilities and a six bedded, dedicated daycase facility.

Oaklands Hospital provides fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of three years for inpatient care) whether medically insured, self funding or from the NHS. The Hospital offers a comprehensive range of treatments and services including ENT procedures, Maxillofacial Surgery, Cosmetic Dentistry, Plastic Surgery, Dermatology Gynaecology, General Surgery, Orthopaedics, Ophthalmics and Urological procedures.

Diagnostic facilities include CT, barium studies, ultrasound, MRI and DEXA for bone density, in addition to general radiology.

All of the Hospital’s consultants are highly experienced and have patient care and comfort as their highest priority. All patients have the reassurance that a resident doctor is available 24 hours/day.

Our physiotherapy clinic is staffed with Chartered, HCPC registered physiotherapists.

Oaklands Hospital is part of the Greater Manchester Critical Care Network and has a Service Level Agreement in place with Royal Manchester Children’s Hospital if transfer of a child is required.

Part 2

2.1 Quality Priorities for 2014/2015

On an annual cycle, Oaklands Hospital develops an operational plan to set objectives for the year ahead.

We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services.

To meet these aims, we have various initiatives ongoing at any one time. The priorities are determined by the hospital’s Senior Management Team taking into account patient feedback, audit results, national guidance and the recommendations from various hospital committees which represent all professional and management levels.

Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.

2.1.1A review of clinical priorities 2013/14 (looking back)

Surgical Safety Checklist - There have been no ‘Never Events’ at Oaklands Hospital in the period and audit of compliance maintains a key focus with monthly audit of WHO safety checklists.

VTE Assessment – There has been continued compliance with completion of VTE documentation for patients where appropriate. Support from Ramsay’s Group Medical Director included a presentation to the Medical Advisory Committee on clinician responsibilities in the completion of VTE risk assessments. Quarterly audit scores have demonstratedthat compliance remains a focus across the whole of the Ramsay Group.

Infection Control – We have had no reportable infections and no outbreaks reported in the period. We continue to screen patients for MRSA where appropriate in line with NHS England guidelines and training for staff on hand hygiene is mandatory. The infection control team have worked to improve standards in environmental cleaning in the period with the Clinical Lead leading quarterly environmental audits in the period. Internal audits demonstrate that compliance remains high, achieving between 97% and 100% in the period.

PLACE (Patient led assessment of the care environment) – The first PLACE assessment was carried out in the year, with patient representatives performing the assessment with members of Oaklands Hospital management, scoring an average of % for the four areas of cleanliness, food, privacy and the condition of facility. The current scoring system of recording NA (Not Applicable) for some sections under Privacy and Dignity are under review as this gives a negative score.

Incident Reporting – The Ramsay Group risk management system ‘RiskMan’ is used to report clinical incidents, health and safety incidents, staff wellbeing and absence together with patient feedback. Additional training has been given to all staff to ensure timely, comprehensive and effective reporting and compliance with reporting has been good. There has been one serious untoward incident reported in the period. This was investigated and identified as a recognised complication of surgery.

Competency Training – Competency assessment tools have been completed for allclinical staff appropriate to their area of practice.

Preoperative Assessment – The preoperative assessment policy is followed and provides safe and efficient assessment of all patients following their outpatient clinic appointment. Patients complete a medical questionnaire which is reviewed by nursing staff to determine the level of preoperative assessment required to ensure the appropriate needs of the patient are met.

Patient Satisfaction Survey – The web based satisfaction survey has been in place since February 2013 and response rates have gradually increased over the period with a response rate of 45.7% at the end of March 2014. The overall satisfaction rate for the year was90.5%.

Patient Reported Outcome Measures Studies (PROMS) – the hospital has encouraged patients to participate in PROMs surveys to monitor patient assessed outcomes of surgery regarding varicose veins, hip and knee replacement and inguinal hernia.

Information Security – Oaklands Hospital has achieved the information security accreditation ISO 27001. The process of raising the importance of data protection and information security has been successful and fully embraced by our staff.

Clinical Documentation Audits -Remain a priority in all areas with a corporate Ramsay focus set for 2014/15 on theatre safety checks and physiotherapy documentation checks.

Local CQUINS

  • Patient Shared Decision Making – this continued for THR patients as per last year and TKR and Carpel tunnel release were added.
  • Care Planning Protocol – care pathways for Laparoscopic Cholecystectomy and Scarf Osteotomy were reviewed and implemented from 1st April 2014.
  • Use of Digital Technology– work continues with the IT teams at the CCG and SRFT to enable the installation of Docman.

National CQUINS

  • Friends and Family Test – The hospital undertook Friends & Family testing with both inpatient and daycase patients in the period, achieving a 42% response rate with a 100% rate for ‘Extremely Likely to Recommend’ from Inpatients and 98% of daycases reporting a “ Likely or Extremely Likely to Recommend”.
  • VTE risk assessment–The hospital was set a compliance target of 95%, the national target being95%, and continuously achieved this reaching 100% compliance in April 2014.
  • Safety Thermometer- continued to submit to NST on a monthly basis with no adverse events reported.
  • Advancing Quality- this initiative is aimed at improving the quality of care and patient experience. In 2014 Oaklands Hospital was recognized with an award for best performing trust participating in one clinical focus area.

2.1.2Clinical Priorities for 2014/15(looking forward)

Patient Safety

Surgical Safety Checklist - Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented as standard practice. Monthly audits will continue to be undertaken with an expectation of 100% compliance; where this is not achieved actions plans will be developed and responsibilities communicated with the teams. Briefing and debriefing sessions after all operating sessions continue and give opportunity for shared learning, recommendations for future practice and aim to encourage autonomy for all members of the team. Compliance will be monitored by regular audit and reviewed by the hospital’s Clinical Governance and Medical Advisory Committees.

NHS Safety Thermometer - The NHS Safety Thermometer is a national CQUIN to measure, monitor and analyse patient harms and ensure 'harm free' care. Oaklands Hospital has been 100% compliant with data submission and will continue to submit this data in relation to pressure ulcers, falls and urinary tract infections in those with a catheter.

VTE Assessment - A VTE risk assessment is completed for patients according to CM 001 VTE policy and requires consultants to review and complete a written assessment prior to procedure. This remains a focus at OaklandsHospital with quarterly audits completed to maintain standards. Results are reviewed and actions determined at both the hospital’s Clinical Governance and Medical Advisory Committees.

Staffing – To ensure adequate numbers of skilled staff are available to care for our patients staff rosters are prepared in advance. An electronic rostering tool ‘Allocate’ was introduced in December 2013 taking into account the necessary skill mix for scheduled patient activity.

The Ramsay Academy provides learning and development opportunities for all staff and the Management Development Framework provides opportunities for our leaders to develop skills and knowledge. We recognise the value of the Health Care Assistant (HCA) within Ramsay and competency assessments are in place to allow all HCAs to reach their full potential. Acknowledging the Cavendish review we are adopting the ‘productive team’ model ensuring ‘a holistic approach to care, focused on ensuring the best possible outcomes for the patient, staff and the organisation’. We promote a culture of support and mentoring in developing our existing staff and will be introducing apprenticeships across different job roles in the next year.

Clinical Effectiveness

Maintaining Endoscopy Standards – Oaklands Hospital will be working towards successful JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation in 2015; biannual submission to GRS (Global Rating Score) continues. This tool enables us to assess how well we provide a patient-centred service, demonstrating compliance against the four domains:

  • clinical quality
  • quality of patient experience
  • workforce
  • training

Patient Experience – informing patient choice

Patient Satisfaction Survey – We will continue to encourage patients to provide feedback using our web based satisfaction survey. ‘Hot alerts’ received following completion of the survey will be reviewed by the hospital’s General Manger and Matron and action taken where there are areas identified for improvement. All comments positive and negative are shared with the whole team along with a monthly patient satisfaction dashboard. Compliments and complaints are reviewed at the hospital’s Clinical Governance andMedical Advisory Committees and lessons shared with the hospital’s departments. We will also continue to monitor posts on NHS Choices.We have added to current patient feedback mechanisms by including patients in hospital PLACE audits.

Friends and Family Test - The Friends and Family Test has been extended to include Outpatients from April 2014. Patients will be invited to complete a paper or electronic questionnaire following their visit to the hospital. Results from this survey will be reviewed and shared with the hospital’s departments.

Patient Reported Outcome Measures Studies (PROMS) – This is a national indicator providing important information regarding the effectiveness of surgery as perceived by the patient. We will continue to monitor patient response rates. The consultant surgeons will continue to ensure patients are fully informed and invited to take part in the survey by completing a questionnaire prior to their surgery.

Advancing Quality – Aimed at improving quality of care and patient experience is a local CQUIN where Oaklands Hospital submits data regarding DVT and antibiotic prophylaxis. Compliance with the best practice pathway is monitored via internal submission of data onto the Clarity database and externally audit of patient records.

Equality Delivery System – Oaklands Hospital will be one of the first private hospitals to work on NHS England’s EDS2 initiative to ensure that the services we provide for patients and that the working environment we provide to staff is free of discrimination, in accordance with the nine protected characteristics under the Equality Act 2010; age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, gender and sexual orientation.