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Cobalt HospitalQuality Account 2013/14

ContentsWelcome to Ramsay Health Care UK 4

Introduction to our Quality Account 5

PART 1 – STATEMENT ON QUALITY 6

1.1 Statement from the General Manager 6

1.2 Hospital Accountability Statement 7

1.2.1 Cobalt Hospital 8

PART 2 9

2.1 Priorities for Improvement 9

2.1.1 Review of Clinical Priorities 2013/14 (looking back) 9

2.1.2 Clinical Priorities for 2014/15 (looking forward) 11

2.2 Mandatory statements relating to the quality of NHS services provided

13

2.2.1 Review of Services 13

2.2.2 Participation in Clinical Audit 14

2.2.3 Participation in Research 15

2.2.4 Goals agreed with Commissioners 15

2.2.5 Statement from the Care Quality Commission 15

2.2.6 Statement on Data Quality 15

2.2.7 Stakeholders views on 2013/14 Quality Accounts 17

PART 3 – REVIEW OF QUALITY PERFORMANCE 18

3.1 The Core Quality Account indicators 20

3.2 Patient Safety 23

3.3 Clinical Effectiveness 26

3.4 Patient Experience 27

3.5 Case Study 29

Appendix 1 – Services Covered by this Quality Account 30

Appendix 2 – Clinical Audits 31

Welcome to Ramsay Health Care UK Cobalt 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 and Clinical Commissioning Groups.

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

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

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

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

Quality Accounts 2013/14 of 32

Introduction to our Quality AccountThis Quality Account is Cobalt 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 did not provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.


Part 11.1 Statement from the General Manager“Cobalt Hospital is committed to being a leading provider of outpatient, diagnostic and day case services by delivering high quality outcomes and an excellent patient experience.”

I am delighted to introduce our Quality Account for 2013/14 which demonstrates our commitment to delivering high quality care. The report focuses upon our performance over the last year and describes our priorities for 2014/15.

Our approach to quality is having in place a robust framework which enables us to monitor and measure outcomes and experience, using this information to drive further improvement in patient safety, patient experience and clinical outcomes. Our team is at the forefront of delivering a quality service. “People caring for people” remains our philosophy and we are committed to training and developing our workforce and ensuring attitudes and behaviour aligned to our values.

This has been a busy and successful year with a wider number of GPs referring to our services and an increased number of patients choosing to access our hospital. Our mission remains, to be expert in delivering elective day case services to patients in our local community and beyond, delivering services we would be happy to receive ourselves. We have had our commitment to quality recognised this year in a number of key achievements:

The number of patients who have taken time to enter reviews on NHS choices and it is particularly pleasing to see that the hospital has an overall 5 star rating

In addition, all of our patient feedback mechanisms show consistently high satisfaction

We meet all CQC standards, an unannounced inspection took place in November and resulted in a very positive report with no conditions

Only 2 complaints received in the last 12 months Obtaining Joint Advisory Group (JAG) accreditation for endoscopy services

Despite these accolades we are not complacent and our priorities for 2014/15 are focused upon ensuring continuous improvement, creating services centred around the patient, getting it right first time and putting patient safety at the heart of everything we do.

Donna Thornton

General Manager, Cobalt 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.

Donna Thornton, General ManagerCobalt HospitalRamsay Health Care UK

This report has been reviewed and approved by:

Peter Hodgkinson, Medical Advisory Group Chair:

Alex Clason, Clinical Governance Committee Chair:

Stefan Andrejczuk, Regional Director:

Who comment that it is gratifying to confirm the high level of service provided by Cobalt Hospital which remains a front runner in the delivery of care in Ramsay Healthcare UK with its continued commitment to improvement and quality of patient care.


1.2.1 Cobalt Hospital

Cobalt Hospital, formerly Cobalt Treatment Centre, was built in 2005 and is a modern, purpose-built unit designed for the diagnosis, assessment and treatment of conditions on a day case basis for adults aged 18 years and over. The Hospital is a single level building comprising of a modern and airy reception area, an outpatient unit with a suite of consulting rooms and a surgical unit housing two theatres and dedicated recovery areas. Located within the Cobalt Business Park there is ample free car parking, good public transport links and easy access to main road networks.

Cobalt Hospital currently provides NHS services for the following specialties: GI endoscopy, general surgery, orthopaedics and plastic surgery. Patients who self pay or have private medical insurance are seen under our Premium Care scheme for the following specialties: cosmetic surgery, GI endoscopy, general surgery, orthopaedics and plastic surgery.

North of Tyne Clinical Commissioning Group were our lead commissioner of NHS Services for 2013/14, on behalf of neighbouring clinical commissioning groups, with regular service review meetings held to discuss performance. Patients were referred and travelled from Northumberland, North Tyneside, Newcastle, Sunderland, South Tyneside and Gateshead.

Referral to the hospital for NHS services is direct from GP via Choose and Book and we have dedicated Choose and Book Co-ordinators and a GP Liaison team to facilitate the referral process. We hold regular Choose and Book workshops at the hospital inviting medical secretaries from local GP practices. These events give an opportunity to tour the facilities and experience the ‘patient pathway’ first hand.

This year saw over 4,500 patient procedures at Cobalt Hospital with a breakdown of work being 97% NHS patients and 3% private patients. In terms of workforce there are 36 members of staff employed at Cobalt Hospital, a mix of full time and part time, of which 51% are clinical posts and 49% support staff.


Part 22.1 Priorities for Improvement 2013/2014On an annual cycle, Cobalt 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 A review of clinical priorities for 2014/15 (looking back)

Surgical safety checklist - There have been no ‘Never Events’ at Cobalt Hospital in the period and audit of compliance maintains a key focus with monthly audit of WHO safety checklists as part of CQUIN indicators undertaken by the Ambulatory Care Team Leader. Scores have ranged from 92% to 100% compliance and action plans are devised where there is evidence of noncompliance. The key area that causes noncompliance is at the sign out stage which will remain a focus in 2014.

VTE assessment – There has been improvement in compliance with completion of VTE documentation for patients where appropriate. Support from the 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 demonstrated improvement and compliance remain 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 DOH 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. Improvements in completion of clinical equipment cleaning schedules have been noted following review of cleaning matrix and clarity of responsibilities. Low scores were in relation to none completion of cleaning schedules. Audit scores have improved from 84% in February 2013 to 92% in February 2014 and a CQUIN target has been set this year to further improve compliance.

PLACE (Patient lead assessment of the care environment) – The first PLACE assessment was carried out in June 2013, two patient representatives performed the assessment with two members of Cobalt Hospital staff including the General Manager and the Infection Control Link Nurse. The patients were both very impressed with the facilities and gave very positive feedback on the day.

Incident reporting – The Ramsay Group risk management system Riskman is used to report clinical incidents, health and safety incidents, compliments and complaints. Additional training has been given to all staff to ensure timely and effective reporting and compliance in reporting has been good. There have been no serious untoward incidents reported in the period.

Competency training – Competency assessment tools have been completed for all staff clinical 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 the nursing staff to determine the level of preoperative assessment required. We have modelled the patient pathway to include early patient assessment expanding boundaries and demonstrating excellence in practice. Our low conversion to inpatient demonstrated by our transfer rate of 1 per 1000 admissions is testament to good patient assessment and planning, setting patient expectation, anaesthetic techniques and staff expertise.

Meeting Endoscopy Standards – Cobalt Hospital was successful in achieving JAG accreditation in September 2013 following a comprehensive assessment. This is a huge achievement for the hospital endorsing the excellent endoscopy service provided to the local community.

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 53.8% at the end of March 2104. The overall satisfaction rate for the year was 97%. We have gained a five staff rating on NHS choices following very positive patient feedback posts describing positive patient experience. We are proud to report that we received only two formal complaints in the period which is a huge achievement and a result we are extremely proud of. We introduced a patient focus group at the end of 2013 involving our staff in reviewing the many forms of


patient feedback we receive and encouraging autonomy in making recommendations for practice.

Patient reported outcome measures studies (PROMS) – Participation rates for patients undergoing inguinal hernia repair remain low and has been a CQUIN target in the period. Return rates have gradually improved with the surgeon actively inviting the patients to complete the questionnaire prior to their surgery and nursing staff are supporting this process. Previous processes involving completion at preoperative assessment yielded poor completion rates. This continues to be a focus.

Information Security – Cobalt Hospital 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.

2.1.2 Clinical 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 for all day case procedures 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 Clinical Governance and Medical Advisory Committee.

VTE assessment - a VTE risk assessment is completed for patients according to CM 001 VTE policy and requires consultants to review and to complete prior to procedure. This remains a focus at Cobalt Hospital with quarterly audit completed to maintain standards. Results are reviewed and actions determined at both 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 the days patient activity. We monitor staff satisfaction with a biannual survey; results for 2013 show a satisfaction score of 4.6 which maintains our position on previous years. 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 recognize the value of the Health Care Assistant (HCA) within Ramsay and competency assessments are in place to allow all HCA’s to reach their full potential. Acknowledging the Cavendish review we are adopting the ‘productive team’ model ensuring ‘an holistic approach to care, focused on ensuring the best possible outcomes for the patient, staff and the organization’.


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 – Following successful JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation in 2013 biannual submission to GRS (Global Rating Score) continues, this tool enables us to assess how well we provide a patient-centered service. Demonstrating compliance against the four domains:

clinical quality quality of patient experience workforce training

At our last GRS audit we demonstrated level A in all domains and we will continue to review and audit against the GRS standards to maintain this level of compliance.

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 General Manger and Clinical Lead 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 Clinical Governance and Medical Advisory Committees and lessons learned shared with the teams. We will continue to monitor posts on NHS choices and commit to retaining our five star recommendations. Our patient focus group will be further developed in the year to include consultant and patient representation to ensure a robust approach to patient feedback; we aim to maintain a satisfaction score of 97%.

Friends and Family Test - The friends and family test is being rolled out to include day case and outpatients from April 2014. This is a national CQUIN indicator this year with a target for early implementation of F&F in outpatients and day case departments by 31st October 2014. Patients will be invited to complete a paper questionnaire or electronic questionnaire following their visit to the hospital. Results from this survey will be reviewed by the patient focus group and shared with the whole team.

Patient reported outcome measures studies (PROMS) – This is a national indicator providing important information regarding the effectiveness of hernia surgery as perceived by the patient. We will continue to monitor patient response rates as part of a local CQUIN indicator with a graduated quarterly target to achieve 75% compliance by quarter four. The consultant surgeon will ensure patients are


fully informed and invited to take part in the survey by completing a questionnaire prior to their surgery.

2.2 Mandatory Statements

The following section contains the mandatory statements common to all Quality Accounts as required by the regulations set out by the Department of Health.

2.2.1 Review of Services

During 2013/14 Cobalt Hospital provided NHS services across four specialties.

Cobalt Hospital has reviewed all the data available to them on the quality of care in all of these NHS services.

The income generated by the NHS services reviewed in 1 April 2013 to 31st March 14 represents 100 per cent of the total income generated from the provision of NHS services by Cobalt Hospital for 1 April 2013 to 31st March 14

Ramsay uses a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year. The scorecard is reviewed each quarter by the hospitals senior managers together with Regional and Corporate Senior Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement.

In the period for 2013/14, the indicators on the scorecard which affect patient safety and quality were:

Human Resource

Staff Cost % Net Revenue 10.4%

HCA Hours as % of Total Nursing 24.4%

Agency Cost as % of Total Staff Cost 1.4%

Admitted Care Hours Worked PPD 3.6

Staff Turnover 10.5%

Sickness 3.07%

Lost Time 17.8%

Appraisal % 100%

Mandatory Training % 100%


Staff Satisfaction Score 4.46

Number of Significant Staff Injuries 0

Patient

Formal Complaints in year 2

Patient Satisfaction Score 97%

Significant Clinical Events 0

Readmission per 1000 Admissions – less than 1 per 1000

Quality

Workplace Health & Safety Score 94%

2.2.2 Participation in clinical audit

The national clinical audits and national confidential enquiries that Cobalt Hospital participated in, and for which data collection was completed during 1 April 2013 to 31st March 2014, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Name of audit / Clinical OutcomeReview Programme

% cases submitted

Elective surgery (National PROMs Programme) Small volumes

The reports of the national clinical audit from 1 April 2013 to 31st March 2014 were reviewed by the Clinical Governance Committee and Cobalt Hospital is working to improve participation rates for preoperative surveys for inguinal hernia repair by consultant engagement with patients preoperatively.

Local Audits

The reports of over 70 local clinical audits from 1 April 2013 to 31st March 2014 were reviewed by the Clinical Governance Committee and Cobalt Hospital ensures action


plans are written with clear time frames for improvement and responsibilities assigned.

Over all good compliance is demonstrated and action plans are completed to ensure improvements are made. Our focus for 2014/15 is to further improve record keeping in relation to VTE compliance and compliance with management of the deteriorating patient.

The clinical audit schedule can be found in Appendix 2.

2.2.3 Participation in Research

There were no patients recruited during 2013/14 to participate in research approved by a research ethics committee.

2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework

A proportion of Cobalt Hospitals income from 1 April 2013 to 31st March 2014 was conditional on achieving quality improvement and innovation goals agreed. Cobalt Hospital and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework.

2.2.5 Statements from the Care Quality Commission (CQC)

Cobalt Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions. On the most recent CQC inspection 11th November 2013 Cobalt Hospital was inspected on outcomes 1, 4, 8, 12 and 21 and full compliance was awarded.

Cobalt Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.

2.2.6 Statement on Data Quality

Cobalt Hospital works hard to ensure accurate data quality is at the heart of everything we do, evidenced by excellent SUS submission rates.

Where applicable, using findings from the internal audit programme, the hospital works to develop data capture and validation methods, ensuring continuous improvement in quality standards.


NHS Number and General Medical Practice Code Validity

Cobalt Hospital submitted records during 2013/14 to the SecondaryUses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included:

The patient’s valid NHS number:

99.97% for admitted patient care; 99.96 for outpatient care; and 0% for accident and emergency care (not undertaken at our

hospital).

The General Medical Practice Code:

100% for admitted patient care; 100% for outpatient care; and 0% for accident and emergency care (not undertaken at our

hospital).

Information Governance Toolkit attainment levels

Ramsay Group Information Governance Assessment Report score overallscore for 2013/14 was 83% and was graded ‘green’ (satisfactory).

Clinical Coding error rate

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


2.2.7 Stakeholders views on 2013/14 Quality Account

Statement from North Tyneside CCG on behalf of Newcastle Gateshead CCG Alliance and Northumberland CCG regarding the Quality Accounts dated 2013/14 for Ramsay Health Care UK:

“NHS North Tyneside CCG as the lead commissioner for services at Cobalt Hospital welcomes the opportunity to provide this statement for their Quality Accounts 2013/2014. The Quality Account has been has been reviewed in accordance with the Department of Health Guidance and Monitor requirements. This statement has been developed in consultation with neighbouring CCGs. Over the past year NTCCG has developed constructive relationships with Cobalt Hospital, reviewing performance at regular Quality Review Group meetings. The Quality Account 2013/2014 is detailed, clear and comprehensive and provides a balanced view of achievement. It reflects the significant increase in activity over the past 12 months, of which 97% were patients referred directly from the NHS.

We acknowledge the achievements of Cobalt Hospital in a number of key areas during 2013/2014 such as VTE assessment and the surgical safety checklist, but would particularly like to offer our congratulations on the achievement of Joint Advisory Group on Gastrointestinal Endoscopy accreditation for endoscopy services in September 2013. We also commend the approach to improving patient experience which continues to be a priority in 2014/2015.

Whilst the CCG is satisfied that the key areas outlined for 2014/2015 are appropriate the CCG would like to see an increase in staff satisfaction from the 4.6 which has been reported over two successive years. Added to this, an improvement in the privacy, dignity and wellbeing element of the Patient-Led Assessments of the Care Environment (PLACE) which was 78.49% in 2013/2014 should be prioritised for improvement in 2014/2015. The CCG would also like to see further evidence of how patients have been involved in shaping Cobalt Hospital throughout 2013/2014.

Overall, this Quality Account is a balanced and accurate view of achievements and outlines how Cobalt Hospital has been working to improve the quality of care it delivers. We will continue to work in partnership to ensure delivery of 2014/2015 quality targets which include an incremental rise in patient reported outcome measures (PROMS) and implementation of Friends and Family Test reporting.”

Statement from Healthwatch North Tyneside:


“The Board notes the generally good performance of your hospital particularly the high patient satisfaction rates at 97%. However, the Board was concerned that the score for “Dignity, Privacy and Wellbeing” on page 27 is only 78.49%. We note that you have an action plan in place to address this and would be grateful if you could keep us informed of progress on this issue. We look forward to a future progress update.”

Part 3: Review of Quality Performance

“This publication marks the fifth successive year since the first edition of Ramsay Quality Accounts. Through each year, month on month, we analyse our performance on many levels, we reflect on the valuable feedback we receive from our patients about the outcomes of their treatment and also reflect on professional opinion received from our doctors, our clinical staff, regulators and commissioners. We listen where concerns or suggestions have been raised and, in this account, we have set out our track record as well as our plan for more improvements in the coming year. This is a discipline we vigorously support, always driving this cycle of continuous improvement in our hospitals and addressing public concern about standards in healthcare, be these about our commitments to providing compassionate patient care, assurance about patient privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open and honest where outcomes and experience fail to meet patient expectation so we take action, learn, improve and implement the change and deliver great care and optimum experience for our patients.”

Jane Cameron, Director of Safety and Clinical Performance Ramsay Health Care UK

Ramsay Clinical Governance Framework 2014The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation.

The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way.

It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All


management systems, clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others.

Several models have been devised to include all the elements of Clinical Governance to provide a framework for ensuring that it is embedded, implemented and can be monitored in an organisation. In developing this framework for Ramsay Health Care UK we have gone back to the original Scally and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of all the necessary strategies, policies, systems and processes for effective Clinical Governance. The domains of this model are:

• Infrastructure• Culture• Quality methods• Poor performance• Risk avoidance• Coherence

Ramsay Health Care Clinical Governance Framework

National Guidance

Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by the NHS Commissioning Board Special Health Authority.


Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that are applicable to our business and thereafter monitoring their implementation.

3.1 The Core Quality Account indicators

National Mortality Rates:

Period Best Worst Average2012/13 RKE 0.65 RXL 1.17 Eng 12013/14 RKE 0.63 RBT 1.15 Eng 1

Cobalt Hospital:Period Cobalt

2012/13 NVC29 02013/14 NVC29 0

Cobalt Hospital considers that this data is as described, we have had no reported deaths.

National Expected Deaths:

Period Best Worst AverageApr12 - Mar13 RBA 0.1 RWH 44.0 Eng 20.4

Jul12 - Jun13 RBA 0.0 RWH 44.1 Eng 20.2Cobalt Hospital:

Period Cobalt2012/13 NVC29 0.02013/14 NVC29 0.0

Cobalt Hospital considers that this data is as described as we do not admit patients for palliative care.


National PROMs: Hernia repair

Period Best Worst AverageApr12 - Mar13 NT415 0.157 NVC27 0.015 Eng 0.085

Apr13 - Sep13 RTG 0.138 RNA 0.019 Eng 0.086

Cobalt Hospital

Period CobaltApr12 - Mar13 NVC29 *

Apr13 - Sep13 NVC29 *

Cobalt Hospital considers that this data is as described as we have low volumes of patients admitted for inguinal hernia repair.

Cobalt Hospital has taken action to improve the returns rate of PROMs questionnaires and so the quality of its services, by actively involving consultants in the PROMs process in encouraging patient participation.

National PROMs Varicose veins

Period Best Worst AverageApr12 - Mar13 RV8 5.14 NT350 -15.92 Eng -8.374

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

Cobalt HospitalPeriod CobaltApr12 - Mar13 NVC29 *

Apr13 - Sep13 NVC29 *

Cobalt Hospital considers that this data is as described as we have low volumes of patients admitted for varicose vein surgery, as the policy around procedures of limited value are followed.

National Readmissions

Period Best Worst Average2010/11 RF4 0.0 RYR 15.8 Eng 11.04


2011/12 RF4 0.0 RYR 15.8 Eng 11.08Cobalt Hospital

Period Cobalt2012/13 NVC29 02013/14 NVC29 0

Cobalt Hospital considers that this data is as described as we have a low level of readmissions reported.

National VTE assessment

Period Best Worst Average

13/14 Q3 Several 100% NT244 63.2% Eng 95.8%

13/14 Q4 Several 100% NT205 67.0% Eng 96.0%

Cobalt HospitalPeriod Cobalt

13/14 Q3 NVC29 98.8%

13/14 Q4 NVC29 100.0%

Cobalt Hospital considers that this data is as described, we monitor compliance monthly and agree an action plan if completion rates drop below 95% maintaining a target above the national average.Cobalt Hospital will continue to audit to maintain the quality of its services.

National C Difficile rate


2012/13 Several 0 RNA 58.2 Eng 22.2

2013/14 Several 0 RVW 30.8 Eng 17.3

Cobalt HospitalPeriod Cobalt

2012/13 NVC29 0.0

2013/14 NVC29 0.0

Cobalt Hospital considers that this data is as described as there have been no reported cases of C Difficile. Cobalt Hospital intends to maintain this rate by ensuring robust infection control measures are in place.

National Patient Safety


2011/12 RP6 2.6 TAJ 84.4 Eng 13.5

2012/13 RRF 2.0 RAT 85.6 Eng 14.8

Cobalt Hospital

Period Cobalt

2012/13 NVC29 0.57


2013/14 NVC29 2.76

Cobalt Hospital considers that this data is as described, we have a low level of patient incidents reported. Cobalt Hospital ensures a safe environment is maintained with all staff undertaking training and competency assessments and a robust audit system. All incidents and accidents are reviewed at clinical governance, health and safety and medical advisory committee and action plans developed and lessons learned shared.

National SUI’s Severity level 1Period Best Worst Average

Jul - Sep 12 NA NA NA

Oct11 - Sep12 NA NA Eng 11,563

CobaltPeriod Cobalt

2012/13 NVC29 0.0%

2013/14 NVC29 0.0%

Cobalt Hospital considers that this data is as described, there have been no level 1 severity incidents reported. Cobalt Hospital intends to maintain this rate by ensuring an effective clinical governance framework.

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.

3.2.1 Infection prevention and control

Cobalt Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 5 years.

We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents year on year.

Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-deployed every two years. Our


IPC programmes are designed to bring about improvements in performance and in practice year on year.

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

Programmes and activities within our hospital include:

The infection control link nurse has provided training in hand hygiene to all staff and completes a hand hygiene training session during the staff induction day for all new staff.

The consultant microbiologist presented a teaching session to the clinical staff entitled ‘Myth busting’ covering universal precaution guidance in clinical practice which was very well received.

In May a hand hygiene awareness day was lead by the infection control link nurse and this involved staff, patients and visitors visiting an information stand in the waiting area. Demonstrations were given and patients and staff were given individual hand hygiene gel dispensers for their own use.

Observational hand hygiene audits were undertaken by the Consultant Microbiologist and Infection Control Link Nurse resulting in additional gel dispensers being placed in the unit. A poster campaign targeting staff to ‘gel in and gel out’ was successful in increasing patient satisfaction scores in questions relating to staff hand hygiene.

Our infection control rate at Cobalt Hospital remains very low and our reporting and investigating of potential infections has improved in the last year. Any patient presenting signs of an infection is reviewed by the infection control link nurse and a root cause analysis completed to determine any possible trends, results are presented at our quarterly infection control committee meetings. There have not been any trends identified in the period.


2011/12 2012/13 2013/140

0.02

0.04

0.06

0.08

0.1

0.12

Infection Rates

Cobalt Hospital

Infe

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Rat

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(per

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age

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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 Cobalt Hospital, providing us with a patient’s eye view of the buildings and facilities, 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.

2013 PLACE results:

Cleanliness - 95.80%

Condition, Appearance and Maintenance - 90.38%

Privacy, Dignity and Wellbeing - 78.49%

An action plan was compiled, as a day case facility patients do not have access to TV radio or internet this reflected a low score for privacy and dignity. Some evidence of high level dust was noted and immediately actioned. An active maintenance programme was introduced to ensure the condition and maintenance of the facilities is maintained to a high standard.

3.2.3 Safety in the workplace

Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high


awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives.

Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues.

In addition to mandatory training the Health and Safety Coordinator has coordinated sharps awareness programmes throughout the year ensuring the use of sharps safe devices where these are available. There has also been training on waste management ensuring the correct segregation of waste taking into account the effect on the environment and raising staff awareness on this issue. We have supported a team member to complete a training course to enable them to provide manual handling training to all of our staff.

3.3 Clinical effectiveness

Cobalt hospital has a Clinical Governance team and committee that meet regularly through the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff feedback are systematically reviewed to determine any trend that requires further analysis or investigation. More importantly, recommendations for action and improvement are presented to hospital management and medical advisory committees to ensure results are visible and tied into actions required by the organisation as a whole.

3.3.1 Return to theatre

Ramsay is treating significantly higher numbers of patients every year as our services grow. The majority of our patients undergo planned surgical procedures and so monitoring numbers of patients that require a return to theatre for supplementary treatment is an important measure. Every surgical intervention carries a risk of complication so some incidence of returns to theatre is normal. The value of the measurement is to detect trends that emerge in relation to a specific operation or specific surgical team. Ramsay’s rate of return is very low consistent with our track record of successful clinical outcomes.


2011/12 2012/13 2013/140

0.05

0.1

0.15

0.2

0.25

0.3

Return to Theatre Score

Cobalt Hospital

Retr

nn to

The

atre

(Per

cent

age

of A

dmiss

iosn

s)

Cobalt Hospital continues to have a very low return to theatre rate as a percentage of overall admissions. There were no trends identified and the increase seen from 2012/13 is still below the national average.

3.4 Patient experienceAll feedback from patients regarding their experiences with Ramsay Health Care are welcomed and inform service development in various ways dependent on the type of experience (both positive and negative) and action required to address them.

All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour – letters and cards are displayed for staff to see in staff rooms and notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly.

All negative feedback or suggestions for improvement are also feedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.

Patient experiences are feedback via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy.

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

Continuous patient satisfaction feedback via a web based invitation Hot alerts received within 48hrs of a patient making a comment on their web

survey Friends and family questions asked on patient discharge ‘We value your opinion’ leaflet


Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback.

Written feedback via letters/emails PROMs surveys Care pathways – patient are encouraged to read and participate in their plan of

care

3.4.1 Patient Satisfaction Surveys

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

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

2012/13 2013/140

204060

80100120

99.1 97.0

Satisfaction ScoresNHS/Private Patients

Cobalt Hospital

Satis

facti

on S

core

s

We have consistently maintained an overall satisfaction rate above 95% and proactively seek patient feedback to ensure we maintain high patient satisfaction rates. A change of satisfaction survey in early 2013 means the data is not comparable.


3.5 Cobalt Hospital Case Study

During 2013 Cobalt Hospital worked towards achieving JAG accreditation. As part of this project an Endoscopy Users Group was developed which included representation from Consultant Gastroenterologists, Endoscopy Lead, Matron, administration and clinical staff.

To ensure patients were represented in the user group the Endoscopy Lead and the rest of the endoscopy team actively sought patient representation and following an episode of care a patient agreed to participate in the endoscopy user group. The patient was subsequently invited to attend the endoscopy user group held in August 2013.

The patient representative reviewed the results of the annual endoscopy patient survey with the endoscopy team and was very impressed with the results saying they reflected her own experience. Two areas were debated: offering a choice of morning or afternoon appointments had been raised in the survey results and the user group committed to review schedules and gastroenterologist availability to ensure choice across the week was offered. Secondly the availability of a private room for patients to have their care discussed with the gastroenterologist was discussed. Whilst the patient representative felt that the individual pods pre and post procedure afforded sufficient privacy a dedicated discharge room was subsequently created as well as access to a private room for the breaking of bad news.

The endoscopy team found the contribution of the patient representative invaluable. In working towards successfully achieving Jag accreditation patient feedback played a key part in the preparation. The Jag assessors commended the endoscopy team on their preparation and excellent endoscopy service provided; they were particularly impressed with the team for inviting a patient representative to join the endoscopy user group.


Appendix 1

Services covered by the Quality Account

Speciality ServiceGeneral Surgery Minor Skin

Varicose VeinsHernia RepairRectal Surgery

GI Endoscopy ColonoscopyFlexible SigmoidoscopyGastroscopy

Orthopaedic Surgery HandKneeShoulderWrist

Plastic Surgery BCCSkin lesions/cysts


Appendix 2 - Clinical Audit Programme 2013/14 (each arrow links to the audit to be completed in each month)


Cobalt Hospital

Ramsay Health Care UK

We would welcome any comments on the format, content or purpose of this Quality Account.

If you would like to comment or make any suggestions for the content of future reports, please telephone or write to the

General Manager using the contact details below.

For further information please contact:

Cobalt HospitalSilverlink North

Cobalt Business ParkNorth Tyneside

NE27 0BY

Tel: 0191 2703 250Email: [email protected] www.cobalthospital.co.ukCentres


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