NEW HALL Hospital
Quality Account
2014-15
New Hall Hospital Quality Account / 2014-2015 /CONTENTS
Welcome to Ramsay Health Care UK / P 3Chief Executive officer statement / P 3
Welcome to Ramsay New Hall Hospital / P 4
Introduction to our Quality Account / P 7
PART 1 – STATEMENT ON QUALITY
1.1 / Statement from the General Manager / P 8
1.2 / Hospital accountability statement / P 10
PART 2
2.1 / Priorities for Improvement / P 11
2.1.1 / Review of clinical priorities 2014/15 / P 11
2.1.2 / Clinical Priorities for 2015/16 / P 14
2.2 / Mandatory statements relating to the quality of NHS services provided / P 187
2.2.1 / Review of Services / P 17
2.2.2 / Participation in Clinical Audit / P 19
2.2.3 / Participation in Research / P 25
2.2.4 / Goals agreed with Commissioners / P 26
2.2.5 / Statement from the Care Quality Commission / P 27
2.2.6 / Statement on Data Quality / P 27
2.2.7 / Stakeholders views on 2013/14 Quality Accounts / P 31
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1 / The Core Quality Account indicators
3.2 / Patient Safety / P 42.
3.3 / Clinical Effectiveness / P 48
3.4 / Patient Experience / P 49
3.5 / Case Study / P 51
Appendix 1 – Services Covered by this Quality Account / P 54
Appendix 2 – Clinical Audits / P55
Welcome to Ramsay Health Care UK
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 32 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs and Clinical Commissioning Groups.
Chief Executive officer statement
The provision of high quality patient care is and will always be the highest priority of Ramsay Health Care UK. Of course our team of clinical staff and consultants are very much at the forefront of achieving this but there is also very much an organisation wide commitment to ensure that we continue to improve out outcomes every day, week, month and year.
Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot be the responsibility of just a few, it takes all of us to be responsible and accountable for our performance in the various roles we all play. Having an organisational culture that puts the patient at the centre of everything we do is key to ensuring we enable everyone to perform at their peak to attain great outcomes.
Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends, we will continue to strive to get ever better.
I am very proud of our long standing and major provider of healthcare services across the world and of our Ramsay very strong track record as a safe and responsible healthcare provider. It gives us pleasure to share our results with you.
Mark Page, Chief Executive officer, Ramsay Health Care UK
Welcome to Ramsay New Hall Hospital
New Hall Hospital is part of the Ramsay Health Care Group and is an independent hospital delivering a full range of specialist surgical and medical services. The hospital is set in beautiful grounds and the original Georgian manor house now accommodates three theatres and 32 beds with excellent physiotherapy and radiology services. Consideration for our patients is at the heart of everything that we do.
We are constantly seeking new ways of working and bringing in fresh clinical practices that will improve outcomes for our patients. Our approach to service delivery, which includes working in partnership with the NHS, is courteous and professional and we take great pride in our ability to innovate and look at new ways of working.
We provide fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of 18 years ) whether medically insured, self-pay, or from the NHS.
We deliver a full range of specialist surgical and medical services (excluding cardiac and neurosurgery) as inpatient and /or outpatient services to include
- General orthopaedics
- Spinal
- ENT
- Ophthalmology
- Maxillo facial
- Gynaecology
- Urology
- General surgery
- Colorectal surgery
- Cosmetic surgery
- Endoscopy
- General medicine to include neurology, cardiology and respiratory medicine
- Oncology
Patients requiring level 2 critical care are treated and cared for by appropriately trained staff in a dedicated high dependency unit and the hospital has transfer arrangements in place with the local trust and critical care network for level 3 care.
In 2014/15 we treated 5943 patients as inpatients, of which 4395 were NHS patients (74%) and 1548 were private patients (26%).
The staff to patient ratio is 1: between 5 and 8 (depending on patient dependence) and there is an experienced Residential Medical Officer (RMO) on site 24 hours a day
New Hall follows the recommendations of the NICE safe staffing guideline: “Safe staffing for nursing in adult inpatient wards in acute hospitals Report on the potential resource implications”, published: July 2014 .
This NICE guideline begins with recommendations for the responsibilities and actions at an organisational level to support safe staffing for nursing in individual acute adult inpatient wards. Although aimed primarily at the acute NHS setting we are committed to attain equal safe staffing levels as recommended in this guidance.
The guideline also makes recommendations for monitoring and taking action according to whether nursing staff requirements are being met and, most importantly, to ensure patients are receiving the nursing care and contact time they need on the day. The emphasis should be on safe patient care not the number of available staff and it is to this that New Hall are committed for both patient safety and quality of care.
There is no single nursing staff-to-patient ratio that can be applied across the whole range of wards to safely meet patients' nursing needs. Each ward or unit determines its nursing staff requirements to ensure safe patient care.
We currently employ
- Consultants (directly employed by Ramsay)4
- Consultants (with practicing privileges)100 (all specialties)
- Registered Nurses44 + 8 bank
- Operating Department Practitioners 6 + 1 bank
- Sterile Services Technicians 4
- Radiographers4+ 3 bank
- Physiotherapists4+ 4 bank
- Health Care Assistants 18+2 bank
- Other Support Staff23 + 7 bank
- Administrative staff 51+ 7 bank
We provide outreach clinic services for outpatient NHS patients at Poole and Dorchester hospitals for spinal services, and at Blandford clinic for general and spinal orthopaedic services.
We offer direct referral services for private cosmetic surgery and aesthetic cosmetic treatments. All patients requiring NHS services are referred via their General Practitioner (GP)
We have a dedicated GP liaison officer who has close contact with both the practice managers and the GPs at practices throughout Wiltshire, Hampshire and Dorset. She visits GP practices and organises regular “Lunch and learn” seminars and breakfast meetings, taking Consultants into GP surgeries to offer training. In addition she also runs regular Consultant led open evenings for GP’s.
We work closely with our local Clinical Commissioning Groups (Wiltshire, Hampshire, and Dorset) to provide a range of surgical services within the standard acute contract.
We work closely with the Salisbury District Hospital who provides us with blood transfusion, urgent pathology, histopathology and access to level 3 critical care services.
We work closely with our community, holding regular charity events, such as coffee mornings, cake sales, tombola to support local and national charities. A team of staff have signed on to a charity run in July and will be sponsored. In addition, the Grand Prize Draw at the Odstock, Nunton and Bodenham local village fairs are sponsored by New Hall Hospital every year.
1
New Hall Hospital Quality Account / 2014-2015 /Introduction to our Quality Account
This Quality Account is Ramsay New Hall hospital’s annual report to the public and other stakeholders about the quality of the services we provide.
It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat.
It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient’s treatment outcomes are the best they can be.
It will give a balanced view of what we are good at and what we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK.
It was recognised that this didn’t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves.
Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.
Part 1 - Statement on quality
1.1: Statement from the General Manager
Welcome to New Hall Hospital’s quality account. This report outlines the Hospitals approach to quality improvement, progress made in 2014-15 and plans for the forthcoming year.
New Hall Hospital has five key values which underpin everything we do as an organisation:
- Put the patient first
- Work as one team
- Respect each other
- Strive for continual improvement
- Respect environmental sustainability
The aim of our Quality Account is to provide information to our patients and commissioners to assure them we are committed to making progressive achievements. For example, we participate in the Public Health England Surgical Site Surveillance Service and Patient Reported Outcome Measures for Hip and Knee replacement, hernias and varicose vein surgery.
Our emphasis is on ensuring patients receive safe, efficient and effective care, that they feel valued, respected and involved in decisions about their care and are fully informed about their treatment each step of the pathway.
The experience that patients have in our hospital is of the utmost importance and we are committed to establishing an organisational culture that puts the patient at the centre of everything we do. As well as being treated quickly and safely, our patients receive a personalised service, enhanced by good communication and a commitment to ensuring their privacy and dignity are respected at all times.
High quality patient care is at the centre of what we do and how we operate our hospital. To do this we rely on excellent medical and clinical leadership plus an overall continuing commitment to drive year on year improvement in clinical outcomes.
We especially value patient’s feedback about their stay, treatment and clinical outcome. In the last year we have received excellent feedback from our internal and external patient surveys. We have also participated in the patient NHS Friends and Family Survey, and have been delighted with the many positive comments we have received.
In 2014-2015 we underwent further significant refurbishment of rooms and were actively in the planning stages for further redevelopment. This redevelopment will include:
•A Third Theatre with new expanded and extended recovery with a 12 bay Ambulatory Unit
•Upgraded and relocated Minor Ops / Endoscopy Suite
•Expansion of the Outpatient Department
•Relocation of Physiotherapy with gym, linked to the Outpatient Department
•Re-housing admin staff and secretaries to purpose built accommodation.
•Addition of Conference Room,
•Extended Car-Park by 51 spaces.
The project has an anticipated completion date of May 2016.
New Hall Hospital continues to focus of delivering high standards of patient care in a friendly and approachable manner. Working with our partners, who include local GPs, Consultants and other specialists, we deliver our patients an individual, personal service tailored to their needs.
Our patients can be assured of the quality of the hospital and its Consultants by referring to the Care Quality Commission (CQC) Audits undertaken by the Department of Health which support the hospital’s excellent reputation.
Fiona Taylor,
General Manager, New Hall Hospital
April 2015
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.
Fiona Taylor
General Manager New Hall Hospital
Ramsay Health Care UK
May 21st 2015
This report has been reviewed and approved by:
MAC Chair: Mr Eunan Tiernan, Consultant Plastic Surgeon
Clinical Governance Committee Chair: Mr David Cox, Consultant Orthopaedic surgeon
Mr Stephan Andrejczuk, Ramsay Regional Director (South)
French Louise (NHS Wiltshire Clinical Commissioning Group);
Joanna Clifford (NHS West Hampshire Clinical Commissioning Group)
Susan O’Flanagan (NHS Dorset Clinical Commissioning Group)
May 21st 2015
Part 2
2.1 Priorities for improvement
On an annual cycle, New Hall Hospital develops an operational plan to set objectives for the year ahead.
We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital
2.1.1 Review of clinical priorities 2014/15 (looking back)
Three main quality indicator priorities were set for 2014/15 cover the domains of patient safety, clinical effectiveness and patient experience
a) Patient Safety Quality Indicator:
As part of improving the patient experience and follow up support following discharge from New Hall Hospital, New Hall was committed to ensuring patients had ready access to support and advice from New Hall following discharge should it be required and so during 2014-15.
This was a local CQUIN agreed with Wiltshire CCG and ensured that patients were being discharged appropriately and with comprehensive follow up advice.
To this end, all Wiltshire NHS patients who had procedures as inpatients or as day cases at New Hall during April and October 2014 were contacted at approximately 30 days following discharge.
The patients were asked whether they had attended their GP or the Accident and Emergency department within 30 days of their New Hall procedure with a concern directly related to that procedure.
A total of 115 patients were contacted by telephone and a response rate of 42% was obtained.
As a result of the initial survey, which indicated that some patients were still not clear about whom to approach following discharge regarding concerns, we wanted to empower patients with clear information about who to approach should they have any post-operative queries or concerns following discharge home.
An action plan was put into place to address concerns that patients might not be aware of the availability of access to care at New Hall following discharge.
Since discharge planning begins at preadmission, meetings were held with the preadmission team to review patient discussion regarding follow up care and pathways during the Pre-Assessment process.
All verbal and written information on post discharge care that was routinely given to take home was reviewed and a clear pathway for contacting for patients to contact New Hall first for all post-operative concerns was developed.
KIT cards (keep in touch card) were designed and ordered to give to patients on discharge. This KIT card was a small credit card size card that the patient could keep in their purse/wallet with clear contact details /hours for contacting New Hall, and was designed to encourage patients to always contact New Hall first with any concerns or queries if practicable.
Six months later, a second, similar survey was undertaken but in an attempt to get a larger response; this survey was done as a simple postal survey with preaddressed return envelopes.
In summary, the survey showed a clear 8% reduction in the number of patients accessing primary and secondary emergency care following discharge between April and October 2014 ,and the evidence suggested that a lack of clarity /communication to patients at preadmission and on discharge had caused patients previously to not initially contact New Hall with post - operative concerns/queries.
The October survey was reassuring in that it evidenced that only one patient six months after the process had been changed, now felt he was unsure that he could contact New Hall on discharge with post-operative concerns.
This quality initiative evidenced the importance of good communication with patients throughout their whole care episode cycle and that patients welcomed giving feedback about their post procedure care experiences.
It was a valuable tool to enable us to give ongoing best continuity of care to our patients following discharge.
Since this patient safety initiative was achieved, it continues to be implemented successfully as standard practice.
b) Clinical Effectiveness Quality Indicator:
Another quality improvement initiative in 2014/15 as part of improving clinical effectiveness, New Hall was committed to reduce the number of avoidable re admissions within 30 days of surgery.
It was planned that this would be monitored via NHS clinical indicators, which would include readmission to other hospitals.