Quality Account 2011/12

Our Physiotherapy Team

People caring for people

No reported MRSA Bacteraemia in the past 3 years

Contents Introduction Page

Welcome to Ramsay Health Care UK and Pinehill Hospital

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 2011/12 (looking back)

2.1.2 Clinical Priorities for 2012/13 (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 2011/12 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 Patient Safety

3.2 Clinical Effectiveness

3.3 Patient Experience

3.4 Case Study

Appendix 1 – Services Covered by this Quality Account

Appendix 2 – Clinical Audits

Welcome to Ramsay Health Care UK Pinehill 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 22 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, PCTs and acute Trusts.

“Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high quality patient care is at the centre of what we do and how we operate all our facilities. This relies not only on excellent medical and clinical leadership in our hospitals but also upon our overall continuing commitment to drive year on year improvement in clinical outcomes.

“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. 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.” 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 Pinehill 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. Previous Quality Accounts were developed by our Corporate Office and summarised and reviewed quality activities across every hospital and 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 hospital produces its own individual Quality Account, including some Group wide initiatives, but focuses on 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 Mr Paul Tempest, General Manager, Pinehill Hospital, Hitchin Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As the General Manager, I am passionate about ensuring that high quality patient care is at the centre of what we do and how we operate our hospital. This relies not only on excellent medical and clinical leadership but also on our overall continuing commitment to drive year on year improvement in clinical outcomes. Pinehill Hospital has a tradition of working closely with Consultants and patients to ensure the best quality healthcare is consistently being delivered. Our hospital staff are fully trained in the latest procedures and thus maintain all areas to the highest standards. Working within the Department of Health guidelines we focus on patient safety and cleanliness to minimise infection. Any patient who wants to satisfy themselves on the quality of the hospital and its’ Consultants can be reassured by the Care Quality Commission (CQC) Audits undertaken by the Department of Health which support the hospital’s excellent reputation. As General Manager of Pinehill Hospital, I take great pride in the service we offer our patients and relatives; this is only achieved through a cohesive team effort and approach. Our Quality Account is information for our patients and commissioners to assure them we are committed to sharing our progressive achievements from one year to the next. As a long standing and major provider for healthcare services across the world, Ramsay has a very strong record as a safe and responsible healthcare provider and we are proud to share our results. Our emphasis is to ensure patients receive safe and effective care, that they feel valued and respected in decisions about their care ensuring they are fully informed about their treatment at each step of their pathway. We especially value patient’s feedback about their stay, treatment and clinical outcome.  The Pinehill Hospital Vision Statement is to be a leading provider of health care services by delivering high quality outcomes for patients and ensuring long term profitability. This vision is reflected throughout the Quality Report in that the hospital will constantly strive to improve the quality and suitability of its services to patients by ensuring there are adequate core policies and skills, effective feedback mechanisms on the quality and efficacy of its activities and processes in place to effect improvement at all levels of the organisation.

In preparing this report, the hospital has taken into account the views of a wide range of stakeholders in the hospital’s activities, including staff, consultants and the Ramsay organisation, but most importantly the views of patients and their families which have been sought though questionnaire survey, comment sheets and focus groups. Furthermore, you are invited to feedback on this document by sending any comments in writing to me at the 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. Paul Tempest General Manager Pinehill Hospital Ramsay Health Care UK This report has been reviewed and approved by: Mr Sanjay Gupta, Medical Advisory Committee Chair Signature................................................... Date........................................................... Mr Peter Hope, Clinical Governance Chair Signature................................................... Date........................................................... Richard Parsons, Regional Director Signature................................................... Date........................................................... Commissioner/PCT and other external bodies PCT Commissioner Signature.................................................. Date...........................................................

Welcome to Pinehill Hospital

Pinehill Hospital Pinehill Hospital is a beautifully converted (see newspaper clipping in office) It is set in excellently maintained gardens on the edge of a residential housing estate. Access to Pinehill Hospital is via Hitchin and is well signposted. Pinehill has 23 in-patient bedrooms, 2 of which are twin-bedded. All rooms have en-suite facilities to ensure privacy and dignity. Additionally there is a detached Day Care Unit with 7 patient bays and 8 further bedrooms. The Hospital has 3 main theatres and a minor theatre/endoscopy suite. The out-patient department has 10 consulting rooms with 2 treatment rooms, a physiotherapy department with gym, an imaging department with x-ray, ultrasound and digital mammography. A CT/MRI van is at the Hospital site 2 or 3 times per week according to patient need. All 137 Consultants are subject to strict vetting procedures to ensure only those with the appropriate experience and qualifications are granted Practising Privileges and offer treatment at Pinehill Hospital. The staff at Pinehill are professional and friendly, delivering high levels of customer service. Together we provide fast, convenient and high quality treatment for patients of all ages (children over the age of 3 years as inpatients), whether medically insured, self funded or via the NHS. Patients can self refer for Vive Cosmetic Surgery consultation, and for some physiotherapy services. Medical and surgical procedures are provided for most specialties, including gynaecology, urology, orthopaedic, ophthalmology, dental, dermatology, physiotherapy. We also provide diagnostic services such as radiology and some pathology on site. Last year (April 2011 – March 2012), Pinehill admitted a total of 2355 patients of which were NHS funded. A well qualified and experienced Resident Medical officer is on site 24 hours/day to provide high quality medical care to patients under the direction of their Consultant. We are very progressive in ensuring that we follow Best Practice wherever possible, constantly developing our staff in order that services are constantly reviewed and further improved according to national guidelines. This also results in high retention and low turnover due to general satisfaction and challenge for all staff.

We have an active recruitment programme, ensuring that replacement staff are recruited into new roles and existing vacancies without unnecessary delay, this results in continuity within the Hospital team, both clinically and otherwise. We can report repeated success in recruiting staff with expired clinical qualifications and supporting them through training to return them to the professional workforce, and indeed we employed two theatre staff with expired qualifications and now they are again fully fledged Operating Department Practitioners (ODP). We also now employ newly qualified staff and ensure a good thorough induction, not only into Pinehill Hospital and Ramsay Health Care, but also to the profession to which they now belong. Whilst there is a national shortage of registered nurses, we are committed to developing our Health Care Assistants (HCAs) through clinical competencies to enable them to undertake more nursing duties and support the registered staff in maintaining clinical standards throughout the patient journey. We are proud to say that the majority of our HCAs have already completed the Immediate Life Support (ILS) course. Our HCAs also fulfill ‘assistant’ roles within physiotherapy, supporting the qualified physiotherapists in the care of patients with ongoing support and exercise. We will shortly be supporting a theatre HCA whilst she completes the NVQ 4 training with an interest in endoscopy so that she may fulfill a valuable role in the care of these patients with confidence and competence. Permanent hospital staff include Registered Nurses, Health Care Assistants, Operating Department Practitioners, Physiotherapists, Pharmacists, Radiographers, administrative staff, caterers, housekeepers, porters and an engineer. Pinehill Hospital is home to the Hertfordshire Phototherapy Centre, providing PUVA and TL01 light therapy for dermatological conditions, together with Iontophoresis. We accept direct referrals to the Hospital services from GPs into Endoscopy and Ophthalmology. We are part of the Eastern Region of Ramsay Health Care and enjoy the services of a GP Liaison Officer, ensuring that the GPs are always in touch with us and informed as to the services that we offer and are developing at any time. We have GP education events planned every 6 weeks or so, including training, networking, certificates and CPD points as well as a hot meal! This year’s programme includes topics around urology, ophthalmology, ENT, joint injections, as well as others. These are always well attended. Our resuscitation officer trains the GP surgery staff in the skills of Basic Life Support and our infection control nurse is preparing some information for presentation at Pinehill. Pinehill Hospital works closely with local Primary Care Trusts in Hertfordshire to support commissioning of healthcare services for the local population. We have close links with the East and North Herts NHS Trust, including histopathology, blood transfusion services and emergency transfer provision.

Pinehill has a very high spirit of community within our team and participate in community activities. Pinehill also supports the Women for Women charity which raises funds to treat life-threatening conditions affecting women and babies. One of our staff members is actually cycling a distance of 450k through America to raise money, a distance from West Wales to Dover! Pinehill has developed close relationships with the local schools, and have some of their art work displayed through the hospital. We also provide educational visits for the students and support junior football teams. Pinehill also provides swift radiological diagnostic services to team players of Stevenage Football Club.

Part 2 2.1 Quality priorities for 2011/2012 Plan for 2011/12 On an annual cycle, Pinehill 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, resulting in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by following 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 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 2011/12 (looking back)

• Bar coding for patient identity bands – this priority did not progress last year, as the Department of Health’s Information Standards Board (ISB) advance notice was not followed up with a formal notice for implementation. Consequently the project was put on hold until further advice was received from the ISB. However, this is still on Ramsay’s agenda and will be introduced this year as it is still considered best practice and will prepare us for many patient care initiatives which will require patients to have a barcode on their wristbands. This is already being encouraged between us and our blood transfusion supplier and will assist in obtaining laboratory results, and electronic record keeping.

• Cleanliness – Further infection prevention and control audits were introduced as planned and these are now being undertaken at all Ramsay sites and action plans developed locally where necessary to ensure the standards are met. PEAT (Patient Environment Action Team) audits were also repeated, with a working group focusing on reviewing our Food Score achievement.

• Meeting endoscopy standards – we are currently registered with the Global Rating Score (GRS) and our dedicated endoscopy team are working towards achieving JAG accreditations.

• Investment in day surgery facilities – patients undergoing day surgery procedures are cared for within our new Day Surgery Unit, comprising of 7cubicles and 8 bedrooms. Our smooth and rapid process means that patients are here for only a few hours prior to discharge.

• Releasing time to care – the Productive Ward project has been very successful so far with staff taking control of stock levels and organisation of care delivery using a patient board system. A bar coding system will be introduced later this year to further facilitate effective and efficient stock levels and ordering. There are also plans for the refurbishment of the clean and dirty utility areas.

2.1.2 Clinical Priorities for 2012/13 (looking forward) Patient safety

1. ‘Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. For further details see: http://www.nrls.npsa.nhs.uk/resources/collections/never-events/ From the core never events, there are 5 that affect Ramsay. • Wrong site surgery • Retained instrument post-operation • Wrong route administration of chemotherapy • Misplaced naso or orogastric tube not detected prior to use • Intravenous administration of mis-selected concentrated potassium chloride

The never event list has recently been extended to 25 never events, of which 21 affect Ramsay – but it is recommended that the core events should be addressed initially.

2. VTE risk assessment - we have successfully improved our VTE rates, obtaining 100% for the latter part of the year. All admitted patients are VTE assessed on admission, using the DH assessment tool. All ward and DSU staff have completed the DH VTE assessment competency training. These assessments are recorded on our Patient Administration System (PAS) for data recording purposes.

3. Medical Gas Alert – Our engineers, portering and clinical staff have all undertaken training on the safe and efficient use of medical gases.

4. Real time incident reporting – The Group are in the process of introducing the RISKMAN system to all units which will further ensure timely and thorough reporting of all incidents at various staff levels throughout the hospital.

5. Pulse results for your hospital – Our Hospital staff survey showed an improvement this

year with positive results. Low achievement levels such as inter-departmental communication has improved with Heads of Department having a set time for a short weekly meeting to discuss ongoing issues and as a support mechanism. Informal staff forums have been introduced and are well attended to ensure ownership and participation. We plan to develop this further with comments being noted in the absence of the management team, and action feedback to staff at subsequent forums.

Clinical effectiveness

1. Ambulatory Day Care – better outcomes and improving patient experience • Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both

medical and surgical) to hospital for a planned procedure, returning home the same day, i.e. within 23hrs 59mins.

• Over recent years, partly due to medical advances the number of day surgery patients has increased compared to those requiring inpatient care. In 2011 the percentage of day surgery patients we treated was 74%. We need to ensure that our hospital facilities and patient pathway flows better to meet the case mix we now deliver.

• We will aim to ensure that 89% of all day care patients are treated in our ambulatory care facilities, cared for by staff who are highly skilled in this type of care delivery.

• In order to do this and provide our patients with a more efficient patient pathway through the hospital, we will be separating the day surgery patient from our inpatients. Best practice has shown that by doing this, patient care will improve as waiting time and recovery period are reduced and patients maintain and retain their independence as soon as possible within their home environment.

• This activity will be monitored through the use of specific codes, and the increased, improved use of our IT systems. The patient satisfaction scores and comments will illustrate satisfaction of patients.

2. Improve National Benchmarking – how do we compare? e.g. It was recognised that we needed more transparency between ourselves and other independent sector providers/the NHS in order to monitor and improve our services. This is even more important now we are working in partnership with the NHS. E.g. benchmarking in the following areas:

Hellenic • Hellenic will provide national benchmark figures for key performance indicators

(such as activity/volumes, mortality, day case rates, unplanned readmissions, average length of stay, unplanned transfers, returns to theatre.

VTE risk assessment compliance • Benchmarking through the national stats website. Link:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_122283

PROMS results

• Benchmarking through national PROMS website. Link: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295

Patient satisfaction figures • Using CQUIN indicators common to both NHS survey and our own (e.g. %

recommended, same sex accommodation, infection rates)

3. Improve ward efficiency by adopting the Productive Ward initiative – more time to care The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for Innovation and Improvement (2008). It focuses on the way ward teams work together and organise themselves, in order to reduce the burden of unnecessary activities, and releasing more time to care for patients in a reliable and safe manner within existing resources. The approach is very much ‘bottom up’ with all ward staff suggesting ideas and ways in which they could improve their environment and processes. We have commenced this project and need to further develop ownership from the staff. We have plans to refurbish and enlarge our clean utility area, allowing more space for the preparation of medications and completing medical records. We also intend to replace old equipment in the dirty utility area, better meeting the needs of infection control guidelines.

4. Improved patient information It was identified last year from our patient satisfaction survey results, that our patients were not always receiving written discharge information on discharge. This is important as even though we always tell our patients everything they need to know before going home, a written reminder ensures that they have the same information should they need to refer to it at a later date. Ramsay have since published a wealth of patient information, which is now routinely given to patients on discharge. We continue to monitor results, which are showing a positive improvement recently. We have also developed local Patient Information Leaflets to cover areas not previously covered in EIDO and Ramsay pre printed materials.

5. Improve Patient Outcome

We have narrowed the ‘gap’ between ourselves and the local NHS Trust with staff experiencing different working practises across both sites. We now have access to traditionally NHS run courses and training and have forged strong links with the infection control, resus and theatre teams to the benefit of all patients.

Patient experience – informing patient choice

1. Increasing the use of Patient Reported Outcomes Studies (PROMs) • Better use of the national PROMs results for Hip, Knee, Varicose Veins and

Hernia surgery. Encouraging their use in identifying poor outcomes and examining practice if and where this exists, via Clinical Governance and Speciality meetings.

• Sharing results with Surgeons (and physiotherapists) and encouraging them to use them to review their practice. This will be achieved through Medical Advisory Committee meetings, specialty meetings and Clinical Governance, Expanding our use of PROMS surveys to cover more procedures will enable better understanding of treatment outcomes from the patients view point.

2. Patient Satisfaction survey

We are very aware that Pinehill is in need of refurbishment and we currently have an active programme underway. The reception area will be enlarged and modernised giving more space and natural light. The main ward area will also be modernised with clean smooth lines fully utilising all the available space as the bathrooms will be replaced with ‘wet rooms’, removing the small cramped space that is current. The clinical care delivery is excellent with 97.6% of our patients scoring us as excellent, very good or good. We offer a very friendly welcome and treat 100% of patients with respect and dignity. We also aim to solve all identified problems as quickly and effectively as possible, attracting a score of 100%. Pain is well controlled, scoring 96.7% and control of nausea and vomiting effectively with a score of 100%. The team now needs to concentrate more on reducing the admission to procedure delay time and also the information provided for discharge.

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 2011/12 the Pinehill Hospital provided and/or subcontracted 22 NHS services. The income generated by the NHS services reviewed in 1 April 2011 to 31st March 12 represents 100% per cent of the total income generated from the provision of NHS services by the Pinehill hospital/centre for 1 April 2011 to 31st March 12. 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 Managers. 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 2011/12, the indicators on the scorecard which affect patient safety and quality were: Human Resources HCA Hours as % of Total Nursing – we aim for a ward/theatre split of 70:30. This has been variable this year due to professional development and return to nursing students as further described in Section 3.4. Agency Hours as % of Total Hours – 15% % Staff Turnover – 9% % Sickness – 9.64% Appraisal % - 84% Mandatory Training % - 97% Staff Satisfaction Score – 64% Number of Significant Staff Injuries - 0 Patient Formal Complaints per 1000 HPD's – 3.25 Patient Satisfaction Score – 94% Number of Significant Events – 84 in 12 months, which includes all reported adverse events through the hospital Readmission per 1000 Admissions – 4.6 Quality Workplace Health & Safety Score – Awaiting inspection Infection Control Audit Score – 91.5% Consultant Satisfaction Score – Not measure at this time 2.2.2 Participation in clinical audit During 1 April 2011 to 31st March 2012, Pinehill Hospital participated in all national clinical audits to which it was invited and was eligible although these numbers were very low due to insufficient or no patient volumes relevant to that particular audit/study. Therefore the only audits that we have been active with for this particular year are the hip, knee and ankle replacements through the National Joint Registry (NJR) and the national PROMs programme. Business at Pinehill has grown and the clinical teams have developed that we may now be in a position to participate in more national audits and this is being reviewed by the Senior Management Team (SMT). Local Audits There is a local audit system in place, based on a Group-wide template, covering areas such as medical records, infection prevention and control, consent, controlled drugs and radiology. The local clinical Governance Committee reviews audit results and recommends/supports appropriate action plans. For example it was identified that the Anaesthetists were inadequately completing the anaesthetic chart of patients. The committee wrote to this group of Consultants with the result of a significant improvement in score.

2.2.3 Participation in Research Pinehill is currently involved in recruiting patients for a research study to identify men with a higher than normal potential to develop prostate cancer: ‘Use of -2PROPSA for the Detection of Prostate Cancer in Men who are Candidates for a Prostatic Biopsy’. This involves blood sampling and analysing of that sample. The study is led by one of our Urology Consultants and is performed in conjunction with patients from the local NHS Trust. It commenced in April 2012, so early days yet, with only a few patients having given consent. The results, when available will be shared nationally by the Consultant. 2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Pinehill Hospital’s income in from 1 April 2011 to 31st March 2012 was conditional on achieving quality improvement and innovation goals agreed between them 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. Measures included VTE Assessment and outpatient follow up rates. 2.2.5 Statements from the Care Quality Commission (CQC) Pinehill Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is full registration without conditions. The Care Quality Commission has not taken any enforcement action against Pinehill Hospital during 2011/1. The CQC came to visit Pinehill Hospital in March 2012 and performed a review of our Termination of Pregnancy process and associated medical records. There were no actions necessary following this review. The Matron, as a representative of our Corporate Director for Safety and Clinical Performance, was part of a working group with the CQC reviewing the process of reporting adverse events with a view to refining the process for the future. 2.2.6 Data Quality Pinehill Hospital will be taking the following actions to improve data quality.

High quality data is considered fundamental to the delivery of high quality services to patients. The hospital is focused on ensuring that high standards are set in all areas of data recording and reporting supported by regular audit of manual and IT systems. As members of the Eastern Region of Ramsay, our medical notes are audited for coding inaccuracies with this region being commended on the accuracy of our data recording.

Pinehill Hospital will be taking the following actions to continue to improve data quality. • Regular audit • Ongoing review of procedures and processes • Training and development of staff • Ensure lessons learned are effectively communicated.

NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2011/12 to the Secondary Users service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: the patient’s valid NHS number was: 99.66% for admitted patient care; 99.30% for out patient care; and 0% for accident and emergency care (not undertaken at Ramsay hospitals). the General Medical Practice Code was: 99.96% for admitted patient care; 99.82% for out patient care; and 0% for accident and emergency care (not undertaken at Ramsay hospitals). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall score for 2011/12 was 77% and was graded ‘green’ (satisfactory). Clinical coding error rate Pinehill Hospital was not subject to the Payment by Results clinical coding audit during 2011/12 by the Audit Commission.

2.2.7 Stakeholders views on 2011/12 Quality Account Awaiting comments.

Part 3: Review of quality performance 2011/2012

Statements of quality delivery Mary Barrett, Matron Introduction

“Our 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”. (Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)

Ramsay Clinical Governance Framework 2012 The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation.

The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way. It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All management systems, clinical, financial, estates 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

NICE / NPSA 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 National Patient Safety Agency (NPSA). 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 Patient safety We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety. Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators. Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below. 3.1.1 Infection prevention and control Pinehill hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 3 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. Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored. Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a Corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year. A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice. Programmes and activities within our hospital include: A ‘live’ scenario set up in a patient bedroom with intentional faults, issues and concerns to be identified by hospital staff. Approximately 65% of staff visited this training area, with varying results. This will be repeated in 2012, and a comparison made as to lessons earned.

From surveys, it was apparent that patients did not observe staff cleansing of hands prior to care delivery. Therefore extra training has been provided to raise awareness of staff so that hands are cleansed where they can be easily observed. Our HAI rate indicates that hand hygiene is scrupulously followed at all times. We have also been completing a monthly hand cleansing audit on a monthly basis scoring an average of 94%. 3.1.2 Cleanliness and hospital hygiene Assessments of safe healthcare environments also include Patient Environment Assessment Team (PEAT) audits. These assessments include rating of privacy and dignity, food and food service, access issues such as signage, bathroom / toilet environments and overall cleanliness. In 2011 the results for Pinehill Hospital were: Environment – good (90.79%) Food – good (83.61%) Privacy and dignity – excellent (100%) The catering team worked hard on last year’s result of ‘acceptable’ with a positive result, scoring ‘good’ this year. Our infection control team has met with all housekeepers and delivered training on the importance of high standard achievement, with the target being to score ‘excellent’ next year. Pinehill staff have adopted a ‘can do, will do’ attitude and although achieving well, are constantly striving for improvement.

3.1.3 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 and then the hospital teams which ensures we keep up to date with all safety issues. Our local Safety Committee has devolved departmental audits for completion on a quarterly basis ensuring safety of staff and hospital visitors at all times. 3.2 Clinical effectiveness Pinehill 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. Incident and near-miss reporting is encouraged, to ensure effective learning in a no-blame culture. Ramsay are now adopting the Riskman system to make reporting easier from all levels of staff.

3.2.1 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.

3.2.2 Readmission to hospital Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness. As with return to theatre, any emerging trend with specific surgical operation or surgical team in common may identify contributory factors to be addressed. Ramsay rates of readmission remain very low and this, in part, is due to sound clinical practice ensuring patients are not discharged home too early after treatment and are independently mobile, not in severe pain etc.

As can be seen from the above graph our readmissions to hospital rate has significantly reduced over the 12 month period as a response to staff development and awareness. This is also as a result of proactivity in the screening of our patients prior to admission, with anaesthetic assessment and referrals to other specialists as appropriate. 3.3 Patient experience All 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 fedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be at all less than 100% happy with any aspect of their care. We are praised in the independent patient feedback system for treating our patients with respect and dignity, attaining 100% satisfaction, and also for rapidly resolving any issues to the individual’s satisfaction. Patient experiences are fedback via the various methods below, and are regular agenda items on Local Governance Committtees for discussion, trend analysis and further action where necesary. 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: Patient satisfaction surveys ‘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 Patient focus groups PROMs surveys Care pathways – patient are encouraged to read and participate in their plan of care

3.3.1 Patient Satisfaction Surveys Our patient satisfaction surveys are managed by an independent company called ‘The Leadership Factor‘ (TLF). They print and supply a set number of questionnaire packs to our hospital each quarter which contain a self addressed envelope addressed directly to TLF, for each patient to use. Results are produced quarterly (the data is shown as an overall figure but also separately for NHS and private patients). The results are available for patients to view on our website. Patient satisfaction scores for overall quality show the majority of patients feel they receive excellent quality of care and service in Pinehill hospital. To record a satisfaction index over 90% a very high proportion of our patients have scored 9 or 10 out of 10 for their satisfaction with all the requirements. This is underlined by comparing our hospitals Satisfaction Index against those achieved by other organisations across all sectors of the UK economy where the full range of customer satisfaction is 50% to 95% with the median just below 80%. Pinehill’s index is 91.65% and rates in the top 2-3% of organisations. Pinehill actively review these results as they become available and compile an action plan each time which is shared with key staff members in order to establish improvement.

3.3.2 Patient Reported Outcome Measures (PROMs) Pinehill hospital participates in the Department of Health’s PROMs surveys for hip and knee surgery, hernias and varicose veins for NHS patients. As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys specifically for private patients. Website to access Pinehill Hospital PROMs scores: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295

3.4 Pinehill Hospital Case Study We at Pinehill identified that although our theatre team were competent in their roles, challenge and enthusiasm was perhaps somewhat lacking. They knew what they were doing but lacked the intimate knowledge of the rationale for their actions. Many had not received/attended update sessions since attaining their original qualifications and had not received the encouragement to further progress this. Over this last year, training and professional development has been positively encouraged for the already registered staff and we have also employed staff whose qualifications have slipped due to non-practice working as a result of family commitments etc. These staff have been employed as Health Support Workers, whilst receiving support from Pinehill to re-attain their qualifications. This ensures a high level of expertise within the department whilst there is a national shortage of registered staff in healthcare nationwide. We have in effect ‘grown our own’. This also ensures a high level of commitment from staff to the unit and encourages others to join due to the individualised personal and professional development programmes. One of our senior physiotherapists was successful in gaining a scholarship funded by Ramsay by submitting a paper around Women’s Health. She has gone on to achieve a PG Certificate in Women’s Health Physiotherapy which will improve the quality of the Women’s Health service through her increased skills and knowledge which she shares with colleagues, both physiotherapists and consultants. She is available to advise patients and will be implementing a Pregnancy Related Lower Back Pain service on her return from maternity leave.

Appendix 1

Services covered by this quality account

Services Provided Peoples Needs Met for: Treatment of Disease, Disorder Or injury

Cardiology, Dermatology, Diabetes and endocrinology, Ear, Nose and Throat (ENT), Gastrointestinal, General medicine, Genito urinary, Gynaecological, Immunology, Nephrology, Neurology, Neurophysiology, Ophthalmic, Orthopaedic medicine, Pain management, Phototherapy (PUVA), Podiatry, Psychiatry, Psychology, Physiotherapy inc acupuncture, Rheumatology, Sports medicine, Satellite outpatient clinics, Urology

All adults 18 yrs and over All children 3 yrs and over

Surgical Procedures

Colorectal, Cosmetics, Day and Inpatient Surgery, Ear, Nose and Throat (ENT), General Surgery, Gynaecological, Maxillofacial, Ophthalmic, Orthopaedic, Urology, Vascular

All adults 18 yrs and over, and children 3 yrs and over excluding:

• Patients with blood disorders (haemophilia, sickle cell, thalassaemia)

• Patients on renal dialysis • Patients with history of malignant hyperpyrexia • Planned surgery patients with positive MRSA screen are

deferred until negative • Patients who are likely to need ventilatory support post

operatively • Patients who are above a stable ASA 3. • Any patient who will require planned admission to ITU post

surgery • Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g.

from kitchen to bathroom or dyspnoea at rest) • Poorly controlled asthma (needing oral steroids or has had

frequent hospital admissions within last 3 months) • MI in last 6 months • Angina classification 3/4 (limitations on normal activity e.g. 1

flight of stairs or angina at rest) • CVA in last 6 months

However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment.

Diagnostic and screening

Audiology, Echo cardiography, GI physiology, Health screening, Imaging services, MRI/ CT, Obstetric, Phlebotomy, Ultrasound, Urinary Screening and Specimen collection

All adults 18 yrs and over Children 3 years and above

Termination of Pregnancy

Surgical Termination of Pregnancy

All female adults aged 16 yrs and over

Quality Account 2011/12  Page 30 

Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.

Au d it P ro g ra m m e v 4 .0 2 0 1 1 /2 0 1 2 Ho s p ita l Na m e : P in e h ill Im plem ented: Ju ly 2011A uthors : R . S aunders / A . S hannon / N. Carre / E . A nders on For review: June 2012 Us e arrow s y m bol to loc ate required audit

JU L AU G S E P OC T N OV D E C JAN F E B M AR AP R M AY JU NAnaesthetic S tandards 9 7 % 8 8 %

M edical Records 9 7 %9 8 9 8 % %9 8 9 1 % 9 8 % 9 8 % 6 3 % 9 7 % 9 6 % 6 4 % 9 8 % 9 3 % N & H

C onsent 9 4 % 8 7 %G re e n 100%

D ischarge 9 6 %Co ol Am b e r 90 - 99%

C are P athw ays and Variance tracking 9 6 % 6 9 %

Am b e r 80 - 89%

C ontrolled D rugs 9 8 % 9 8 %97% Ho t

Am b e r 70 - 79%

P rescribing 9 9 % 9 8 %Re d 69% a nd u nde r

M edicines M anagement 9 6 % 9 8 %

Radiology 9 3 % 1 0 0 % 9 9 % 9 4 % 9 8 % 9 6 % 9 7 % 9 5 %

P hysiotherapy 95% 97% 96% 99%

Theatre

Infection P revention and C ontrol* 9 2 % 9 4 % P VC C B

UCCB9 4 %

H a n d h yg ie n e 1 0 0 % S S I 9 2 .5 3 % 9 5 % 9 0 % U C C B

Infection P revention and C ontrol - Env ironmenta l Audit 9 6 % 9 5 % E n viro n 9 7 %

Transfusion 9 6 % 1 0 0 % 9 1 %

P VC C B = P e rip h e ra l Ve n o u s C a th e te r C a re B u n d le

Cop yrig h t © 2011 Ra m sa y He a lth Ca re UK

N & H = N u tritio n a n d H yd ra tio n

D e t P t = D e te rio ra tin g P a tie n t

U C C B = U rin a ry C a th e te r C a re B u n d le

T raffic light score

*Ke y:

C VC C B = C e n tra l Ve n o u s C a th e te r C a re B u n d le

S S I = S u rg ica l S ite In fe ctio n

P E AT = P a tie n t E n viro n m e n t Actio n Te a m

Quality Account 2011/12  Page 31 

Pinehill 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:

01462 422 822

www.pinehill-hospital.co.uk Neurological Centres