Nottingham Woodthorpe Hospital
Quality Account
2013/14
Contents
Introduction PageWelcome 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
.2.7 / Stakeholders views on 2010/11 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
Welcome to Ramsay Health Care UK
Nottingham Woodthorpe Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Group.
“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 Nottingham Woodthorpe Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient’s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.
Part 1
1.1 Statement on quality from the General Manager
Simon Milner, General Manager
Nottingham Woodthorpe Hospital
As General Manager of Nottingham Woodthorpe Hospital, I believe that this hospital is clinically driven and our goal is to support our clinicians in delivering the highest quality care to our patients.
Not only that, but we aim to produce evidence to this effect whether it be qualitative or objective – we will be able to demonstrate our capabilities, and clinical excellence.
Our Hospital Vision is that:-
“As a committed team of professional individuals we aim to consistently deliver quality holistic Acute Inpatient and Day Case Services with exemplary customer care. This we believe we are able to achieve by continually updating our staffs’ skills and competencies. We strive to further develop our knowledge in order to deliver evidenced based clinical practice”.
This Quality Accounts document details our performance over the past year indicating how we have improved on the high standards of clinical care the actions that we have taken over the past year.
Quality extends not only to the service we deliver to our patients but to our other customers – Consultants, GPs, Commissioners, other Trusts and by no means last, the people who work for us. To understand how we deliver our services, and the quality standards we reach is critical in our understanding of where we can improve and how.
Where appropriate, Nottingham Woodthorpe Hospital participates in local, corporate and national systems of quality review that are sometimes mandatory, sometimes voluntary, but all times we are honest in our responses. It is to our benefit that we benchmark honestly against our peers, and that we take the opportunity to learn from those facilities and people delivering better outcomes, in order to drive up our own standards Quality Accounts 2014/15
To ensure that we deliver clinical excellence depends on everyone in our hospital and we have a training and education plan which involves all members of our administrative, operational and clinical teams. The emphasis on training and education is high and strongly encouraged in order that we develop our people, as well as deliver standards that we can be proud of.
Every individual member of staff is crucial to the success of our Hospital and they value the contribution that they make in delivering great customer care.
In addition to our people contributing to the quality of services delivered, we work closely with our consultant colleagues who, for the first time this year through their MAC representatives, have responded positively to sharing the outcomes of their clinical work in many areas. This is to be commended, but at the same time, will be something Nottingham Woodthorpe Hospital can be proud to show, as we pride ourselves in having consultants with the highest standards in the area
To ensure a coordinated approach to the delivery of care for patients and to monitor the adherence to professional standards and legislative requirements the Clinical Governance Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and safety performance of the hospital. These committees have reviewed and commented on the details within these Quality Accounts.
If you would like to comment or provide me with feedback then please email at or contact on 0115 920 9209
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.
Simon Milner
General Manager
Nottingham Woodthorpe Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Ramsay Health Care UK Regional Director: James Beech
CCG Lead: Linda Clarke
Medical Advisory Committee (MAC) Chair: Mr Anwar Zaman (sent and response awaited)
Clinical Governance Committee Chair: Dr Ndu Okonkwo (sent and response awaited)
Welcome to Nottingham Woodthorpe Hospital
Nottingham Woodthorpe Hospital has provided healthcare to the people of Nottingham since 1877 and is conveniently located towards the north of Nottingham city centre.
Today, we are a modern well equipped hospital with 41 private bedrooms (including a Level 2 High Dependency Unit), two theatres (with laminar air flow), and a Minor Procedures Theatre with Endoscopy Suite and 10 Consulting Rooms.
The hospital provides NHS and private inpatient and outpatient facilities for:-
· Orthopaedic surgery
· General surgery including gastrointestinal
· Gynaecology
· Bariatric surgery
· Colorectal surgery
· Cosmetic and Plastic surgery
· Dermatology
· Upper and lower diagnostic Endoscopy procedures
· Ophthalmic surgery
· Oral and Maxillofacial surgery
· Spinal surgery
· Vascular surgery
· Urological surgery
· General medicine
· Physiotherapy, including shockwave therapy, Sports Medicine and acupuncture
· Diagnostic imaging services including MRI and CT
We provide safe, convenient, effective and high quality treatment for adult patients (excluding patients below the age of 18 years), whether privately insured, self-pay, or from the NHS.
A high percentage of our patients have come from the NHS sector with patients choosing to use our facility through “Choose and Book‟. Our services help to ease the pressure on local NHS facilities and our Hospital Management Team work closely with local CCGs and the local NHS Trust to ensure improved access for patients and relief on bed pressures, as required. In addition, Nottingham Woodthorpe Hospital has undertaken some work with the CCGs outside the Standard Contract.
We have close links with GP surgeries, providing information, training and liaison in order to monitor their needs and the requirement of the local population.
For the Year-to-date (July 2013 to end-May 2014) Nottingham Woodthorpe Hospital has seen 4,413 admissions:
· Insured: 7.5% (331 patients)
· Self-Pay: 6.0% (265 patients)
· NHS: 86.5% (3,817 patients)
Nottingham Woodthorpe Hospital employs the following staff
Senior Management Team
· General Manager
· Matron
· Operations Manager
· Finance Manager
· Sales & Marketing Manager
Clinical Departments
Managers
· Surgical Ward Manager
· Medical Ward Manager
· Theatre Manager
· Outpatient Manager
· Physiotherapy
· Radiology
· Pharmacy
· Decontamination Lead
19 Registered Nurses working within the Ward, Outpatients and Theatres
8 Senior Staff Nurses working within the Ward and Theatres
1 Senior Operating Theatre Practitioner
4 Operating Department Practitioners
18 Health Care Assistants working within all clinical departments
2 Radiographers
1 Sonographer
1 Senior Physiotherapist
2 Physiotherapists
1 Pharmacy technician
3 Sterile Services Technicians
29 Administration Staff working within Reception, Bookings, Business
Non-Clinical Departments
1 PA to GM
1 Reception/Admin Team Leader
13 administration staff in Business Office, Hospital Administration, Medical Secretaries and Medical Records
1 GP Liaison Manager
1 Hospital Services Advisor
1 Supplies Manager
1 Maintenance Manager, 1 Assistant Maintenance Assistant
2 Theatre Porters
1 Housekeeping Team Lead
5 Housekeeping staff
2 Chefs supported by 6 Catering staff
GP Communication
Nottingham Woodthorpe Hospital employs a GP Liaison Officer who maintains and establishes relationships with GPs and the practice staff from Nottingham and the surrounding areas. A GP visit schedule is maintained whereby surgeries are contacted and visited on a regular basis. GPs are sent regular newsletters and updates, and information packs containing details about the hospital and how to refer are distributed.
Nottingham Woodthorpe Hospital delivers a programme of educational visits during practice learning times whereby a consultant and the GP Liaison Officer will visit GP surgeries with a topic of interest for a “Lunch & Learn” session. GP Educational evenings are also held at the hospital.
Outside activities which show an involvement in the community include hosting public open evenings for various clinical specialities.
Part 2
2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, Nottingham Woodthorpe Hospital develops an operational plan to set objectives for the year ahead.
We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2013/14
Patient Safety
WHO Surgical safety checklist
This has been implemented effectively to ensure that the highest possible safety standards pre-operatively are ensured before and during all operations undertaken in the facility.
Venous-Thromboembolism assessment
In September 2008, the Department of Health issued its guidance on Risk Assessment for Venous Thromboembolism (DH 2008). The objective is to improve the quality of patient care by minimising the risk of VTE incidents. Nottingham Woodthorpe Hospital submits data to evidence compliance with the National VTE Commissioning for Quality and Innovation Goal that all patients should have a VTE risk assessment. Nottingham Woodthorpe Hospital’s priority for 2013/14 was to maintain and improve the current compliance rate.
Cleanliness and infection prevention
The hospital continues to screen all patients for MRSA prior to admission and all staff has a mandatory requirement to undertake hand hygiene training. We maintain our regular audit programme which includes hand hygiene, urinary catheter and intravenous line care, and our cleaning standards and physical environment. We also participate in the Health Protection Agency data collection for surgical site infections following hip and knee joint replacements.