Quality Accounts 2011 /12

Quality Accounts 2011 /12

Contents Contents Page

2

Welcome to Ramsay Health Care UK

4

Welcome to Clifton Park NHS Treatment Centre

5

Introduction to our Quality Account

6

PART 1 – STATEMENT ON QUALITY 1.1

Statement from the General Manager

7

1.2

Hospital accountability statement

9

PART 2 – QUALITY PRIORITIES AND MANDATORY STATEMENTS 2.1

10

Quality Priorities

2.1.1 Review of clinical priorities 2011/12 (looking back)

10

2.1.2 Clinical Priorities for 2012/13 (looking forward)

15

2.2

Mandatory statements relating to the quality of NHS services provided

19

2.2.1 Review of Services

19

2.2.2 Participation in Clinical Audit

20

2.2.3 Participation in Research

23

2.2.4 Goals agreed with Commissioners

23

2.2.5 Statement from the Care Quality Commission

23

2.2.6 Statement on Data Quality

23

2.2.7 Stakeholders views on 2011/12 Quality Accounts

25

PART 3 – REVIEW OF QUALITY PERFORMANCE 3.0

Review of quality performance

28

3.1

Patient Safety

30

3.1.1 Infection prevention and control

30

3.1.2 Cleanliness and hospital hygiene

32

3.1.3 Safety in the workplace

32

3.2

33

Clinical Effectiveness

3.2.1 Return to theatre

33

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3.2.2 Readmission to hospital

34

3.3

35

Patient Experience

3.3.1 Patient satisfaction surveys

36

3.3.2 Patient reported outcome measures (PROMS)

38

3.4

40

Case Study

Appendix 1 – Clinical Audits

42

Appendix 2 – CQUIN schedule

43

Appendix 3 – Managing your pain after your operation

58

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Welcome to Ramsay Health Care UK Clifton Park NHS Treatment Centre 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)

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Welcome to Clifton Park NHS Treatment Centre Clifton Park NHS Treatment Centre was purpose built and opened in January 2006 to deliver elective NHS activity. In October 2010 the hospital secured a three year standard acute contract (SAC) with NHS NYY and NHS ERY to deliver orthopaedic services. In addition to this SAC activity, additional orthopaedic activity from York Trust is undertaken. The hospital is also recognised by most major insurance companies and undertakes self pay and insured work.

Brief description of unit and facilities Clifton Park NHS Treatment Centre is a 24 bedded in patient unit providing a wide range of elective orthopaedic surgical procedures including treatments for problems with hips, knees, shoulders, hand, wrist and elbow and foot and ankle. The hospital has a large out patients department, on-site x-ray and physiotherapy (including a small gym), mobile MRI, a day case unit, two laminar flow theatres and a restaurant which is open to staff, patients and visitors. The hospital provides a full range of high quality orthopaedic services, these include, outpatient consultation, outpatient procedures, investigations/diagnostics, surgery and follow up care for all patients of 18 years and above. From 1st April 2011 to 31st March 2012 the hospital has treated 2884 admitted patients, 95% of which were treated under the care of the NHS. The hospital has a unique structured secondment agreement with York Teaching Hospitals NHS Foundation Trust who provide 40 specialist consultant orthopaedic surgeons and anaesthetists to work from the facility. The hospital also has a training agreement with York Trust, enabling registrars and extended scope practitioners to work alongside consultants at the hospital. Our seconded clinicians are supported by a team of 41 Nursing staff, 11 Health Care Assistants, 12 Allied Health Professionals and 41 support staff which includes porters, hotel services and 23 administration staff. The hospital’s Resident Medical Officer is on site 24 hours a day, working alongside these teams. Our staff-to-patient ratios are managed on a daily basis to meet the individual clinical requirements of our patients. As well as our secondment agreement with York Teaching Hospitals NHS Foundation Trust, we have in place several service level agreements with them to facilitate our service delivery and ensure continuity of care.

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Introduction to our Quality Account This Quality Account is Clifton Park NHS Treatment Centre’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. Each Ramsay site has developed its own Quality Account. It includes some Group wide Initiatives, but describes the many excellent local achievements and quality plans that we would like to share.

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Part 1 1.1 Statement on quality from the General Manager Debbie Craven, General Manager, Clifton Park NHS Treatment Centre “Clifton Park NHS Treatment Centre successfully delivered the GC4 contract from January 2006 to September 2010. In October 2010 we commenced a three year standard acute contract, commissioned by NHS NYY and NHS ERY following a tender process where we demonstrated our continuing high level of quality service delivery.” This is the second Quality Account to be submitted by Clifton Park NHS Treatment Centre (CPTC) and has been produced to demonstrate our commitment to measuring all feedback from patients about their experience, clinical treatment and clinical outcomes. This allows us to continually review, reflect and improve the patient’s journey. Our hospital vision statement, which will be reflected throughout this report, is that: “Clifton Park NHS Treatment Centre is committed to being a leading provider of orthopaedic health care services by delivering high quality outcomes for patients at efficient cost ensuring profitability.” Patient safety is our highest priority and our robust recruitment processes and training programmes ensure that staff are competent and fully trained in all aspects of service provision. Clifton Park NHS Treatment Centre continually achieves consistently high patient satisfaction scores and, by studying results throughout the year, we constantly seek ways to further improve the patient experience. Clifton Park NHS Treatment Centre is committed to ensuring that patients are kept fully informed about their treatment, which is also a significant factor associated with improving treatment outcomes. We involve our patients in treatment decisions at the earliest stage so that the options and benefits are fully discussed before patients consent to treatment. Our medical and clinical teams recognise the importance of devoting time to patient preparation for surgery, which not only reduces risk but also improves patient understanding and confidence, reduces anxiety, improves rates of recovery and shortens lengths of hospital stay. Whilst patient feedback and involvement is extremely important to us, we also rely heavily on other measures of safety and clinical effectiveness which we use to satisfy ourselves that treatment is evidence-based and delivered by appropriately qualified

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and experienced doctors, nurses and other key healthcare professionals. Examples of these are detailed in this Quality Account. Clifton Park NHS Treatment Centre is accustomed to the disciplines of regulatory and contractual requirements to assure healthcare commissioners of our clinical performance and to report complaints and serious incidents to regulators and commissioners. We also maintain a Risk Register and systematically review specific actions to achieve risk reduction.

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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.

Debbie Craven General Manager Clifton Park NHS Treatment Centre Ramsay Health Care UK

This report has been reviewed and approved by:

Mr Ian Whitaker – MAC Chairman

Mrs Gwenn Mather - Clinical Governance Chair

Mr Stefan Andrejczuk – Regional Director, North

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Part 2 2.1 Quality priorities for 2011/2012 Plan for 2011/12 On an annual cycle, Clifton Park NHS Treatment Centre develops an operational plan to set objectives for the year ahead. We have a clear commitment to our patients and, as an NHS Treatment Centre we work in close partnership with the NHS, ensuring that those services commissioned to us result in safe, quality treatment for all patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services. To meet these aims, we have various initiatives ongoing at any one time. The priorities are determined by the 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 Patient Safety •

Falls - Each year around 282,000 patient falls are reported to the National Patient Safety Agency (NPSA) from hospitals and other health units.’ (Jan 2011, NHS NPSA/20111RRR001). From October 2010 monitoring and reporting of patient falls has been included in Schedule 3 part 4: Quality Requirements and Nationally Specified Events as a quality requirement that Clifton Park are required to report against quarterly to NHS NYY and NHS ERY. The threshold is 14 falls per year, should the number of falls exceed this then a remedial action plan would be agreed following which any subsequent breach would result in 2% of the monthly revenue been withheld until the threshold is met.

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To maximize patient safety all patients are asked to complete a medical questionnaire which is assessed by the POA team to identify any potential risks prior to admission. On admission a “risk of falls assessment” is performed for every patient by the admitting nurse, this is reviewed daily and care altered accordingly. Information for patients on how to minimize the risk of falls following surgery/procedures is displayed in all patient bedrooms. Any slip/trip or fall is reported through our robust Risk Management Committee and at our quarterly Quality and Performance meeting. We identify any trends, formulating and implementing action plans across the hospital to help improve patient safety.

Slip/trips/falls recorded/reported

The improvement seen since 2010/11 is attributed to the introduction of a comprehensive action plan focusing on assessment and patient information to reduce the risk of falling with a positive outcome in the reduction of incidents. VTE risk assessment – Clifton Park NHS Treatment Centre carries out a VTE risk assessment on all admitted surgical patients as per Ramsay Policy No CM001 and adhering to National Institute for Clinical Excellence (NICE) Guidance 2010. All nursing staff have undertaken VTE competency assessment via DoH on line assessment tool. From 1st October 2010, Clifton Park NHS Treatment Centre entered into a contract for the provision of NHS services through the Commissioning for

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Quality & Innovation Payment Framework (CQUIN). Payment is conditional on achieving quality improvement and innovation goals, this includes VTE risk assessment. Compliance is audited through a robust corporate and local audit programme and results/action plans reviewed through Clinical Governance.

VTE compliance results are benchmarked through the National Statistics at http://www.dh.gov.uk/en/publicationsandstatistics/Publications/Publicatio nsStatistics/DH

National Joint Registry (NJR) – Clifton Park NHS Treatment Centre participates in the National Joint Registry audit programme. Patients undergoing hip or knee replacement surgery are asked to consent to their information being placed upon the NJR including details of their prosthesis. The NJR provide a quarterly report to the hospital regarding compliance. Clifton Park exceeds the national 90% benchmark figure for NJR consent as demonstrated in the results below, however NJR consent compliance has fallen in the last 2 quarters an action plan will be developed to address this. As was previously the case for submission of BMI rate which has increased over the past year as tabled.

Clifton Park NHS Treatment centre Submission Volumes Consent & link ability % BMI Rate %

2010/11 2011/12 2011/12 2011/12 2011/12 Q4 Q1 Q2 Q3 Q4 235 211 214 197 204 97 94 93 98 98 97 63 93 98 98

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Clinical Effectiveness Better outcomes and improving Patient experience •

Ambulatory Day care is the admission of selected patients to hospital for a planned procedure, returning home the same day. It is our aim that 90% of our day surgery patients are treated in our Ambulatory care facilities. At present our following day case statistics are: Knee arthroscopy Bunion surgery Dupuytrens Carpal Tunnel Overall

= 96% = 76% = 100% = 100% = 93%

As part of Ramsay’s National Project for Ambulatory Day Care services, Clifton Park NHS Treatment Centre has: • • • •

Appointed an Ambulatory Care lead nurse who is a member of the British Association of Day care Surgery (BADS). Facilitated the ambulatory process by aiming to place day care patients first on operating lists or as clinically indicated. Developed an action plan to implement staggered admission times where appropriate to improve the patient experience, aiming to reduce the waiting time from admission to procedure. Further enhanced efficiencies at Clifton Park NHS Treatment Centre by implementing a nurse led discharge service within our Ambulatory day care unit.

On discharge, patients are provided with contact details should they have any post operative problems and receive a post discharge phone call within 48 hrs of discharge. Patient survey results indicate an improvement in waiting time from admission to procedure, to 82.5% satisfaction, due to the staggered admission times in the Ambulatory Day care unit. Pain control - Patients have the right to care that promotes comfort and minimizes pain. Ramsay Healthcare set up a committee of experienced Clinicians to develop guidelines and protocols for pain control following surgery. A member of Clifton Park Treatment Centre’s clinical team was part of this committee and we were also a pilot site for the policy implementation. Taking into account NICE and other best practice guidance, (Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020); Nursing and Midwifery Council (2007) Standards for Medicine Management) the following were introduced:

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A policy on “Acute post-operative pain management in Adults”; a pain assessment tool, and a patient information leaflet “Managing your Pain after your operation” have all been implemented very effectively and patient survey outcomes indicate 100% satisfaction for Quarter 4 2011 and Quarter 1 2012 Everything possible done to control pain 60%

70%

80%

90%

100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.1% 98.2% 98.2% 97.6% 97.5% 97.4% 97.1% 96.7% 96.4% 96.2% 95.8% 95.8% 95.6%

Park Hill Rowley Oakland's Kendal Basildon PPU Euxton Mount Stuart Woodland Ashtead Winfield Bodmin Boston Cobalt Blakelands Tees Valley Clifton Park Horton Fitzwilliam Springfield Fulwood West Midlands Renacres Yorkshire Clinic Oaks Woodthorpe Pinehill Rivers Duchy New Hall North Downs Berkshire Independent

93.3%

Quarter 1 2012

Quarter 4 2011

Patient experience – informing patient choice •

Patient Satisfaction survey - Improved patient information It was recognised from our patient satisfaction survey results, that our patients were not always receiving written information about their proposed surgery. We do have a very comprehensive “Eido” information library; however it does not cover some of the more complex procedures undertaken by our Consultants. We are now in the process of creating further patient information leaflets in partnership with our Consultants. This is important as, even though the Consultants discuss the procedure in depth during the consultation, written information ensures that the patients have something to refer to should they need to at a later date. Written information about proposed treatment before admission 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 90.80%

94.30%

Q1 2011

Q1 2012

40.00% 30.00% 20.00% 10.00% 0.00%

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•

Increasing the use of Patient Reported Outcomes Studies (PROMs) – Clifton Park NHS Treatment Centre uses the National PROMS results for hip and knee replacements. These are used to gain a better understanding of treatment outcomes from a patient point of view. Results are shared with Consultants at our Clinical Governance meetings. All members of the multi-disciplinary team are encouraged to review the PROMs outcomes and changes made as required to improve the patient experience. Compliance rate of submitting completed consented forms 100% 90% 80% 70% 60% 50% 40%

87.50% 77%

30% 20% 10% 0% Hips

Knees

NB: National compliance rates: • 79.6 % hips • 81.9% knees

2.1.2 Clinical Priorities for 2012/13 Patient Safety •

VTE Risk Assessment & the NHS Safety Thermometer (with effect from April 2012) This is a mandatory section of Quality Requirements and Nationally Specified Events (CQUIN) that we are required to report on. In addition to Venous Thrombo Embolism (VTE) compliance and falls previously recorded, the other reportable elements are Pressure Ulcers and Urinary Tract Infections in those with a catheter. We have therefore identified this as clinical priority for 2012/13. In order to demonstrate compliance with this measurement and to establish quality improvement aims, a monthly 24 hour prevalence audit on a single day per month, using the NHS Safety Thermometer Survey tool is conducted and submitted on line.

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VTE is a significant cause of mortality, long term disability and chronic ill health, VTE has been recognised as a clinical priority for the NHS by the National Quality Board. Clifton Park NHS Treatment Centre carries out a VTE risk assessment on all admitted surgical patients as per Ramsay Policy No CM001 and adhering to National Institute for Clinical Excellence (NICE) Guidance 2010. The priority for 2012/13 is to maintain our 100% compliance result therefore reducing the risk of patients suffering a venous thrombo embolism. To maximize patient safety all patients are asked to complete a medical questionnaire which is assessed by the POA team to identify any potential risks prior to admission. On admission a “risk of falls assessment” is performed for every patient by the admitting nurse, this is reviewed daily and care altered accordingly. Information for patients on how to minimise the risk of falls following surgery/procedures is displayed in all patient bedrooms. Any slip/trip or fall is reported through our robust Risk Management Committee and at our quarterly Quality and Performance meeting. We identify any trends, formulating and implementing action plans across the hospital to help improve patient safety. In 2012/13 we would aim to see a further reduction in the number of patients who have suffered a fall in hospital. •

A new Pathology service is being utilised from April 2012, providing both off-site analyses and onsite Point of Care Testing (POCT) and analyses. The advantage of the service is the ability to access electronic reports immediately, ensuring an efficient safe service for patients. A very comprehensive Blood Transfusion Service continues to be provided by York Trust Hospital under a Service Level Agreement.

Clinical Effectiveness - Better outcomes and improving Patient experience •

Pain control - Patients have the right to care that promotes comfort and minimises pain. Ramsay Healthcare have set up a committee of experienced Clinicians to develop guidelines and protocols for pain control following surgery. Taking into account NICE and other best practice guidance, (Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020); Nursing and Midwifery Council (2007) Standards for Medicine Management) the following were introduced. A policy on “Acute post-operative pain management in Adults”; a pain assessment tool, and a patient information leaflet “Managing your Pain after your operation” have all been implemented very effectively and patient survey outcomes indicate 100% satisfaction for Quarter 4 2011 and Quarter 1 2012. At Clifton Park NHS Treatment Centre it is seen as a priority that we continue to

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improve the patient experience and reduce pain following surgery. We have introduced a local survey of all admitted patients to include questions: 1. 2. 3.

Were you ever in pain? Did staff do everything possible to control your pain? Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?

We would aim to have at least a 90% rate of patients responding ‘Yes’ to questions 2 and 3. •

Ambulatory Day care is the admission of selected patients to hospital for a planned procedure, returning home the same day. It is our aim that a minimum of 90% of our day surgery patients are treated in our Ambulatory care facilities. At present our following day case statistics are overall 93%. Patient survey results indicate an improvement in waiting time from admission to procedure, to 82.5% satisfaction. Further focus is required to improve this satisfaction rate further by developing the staggered admission times model. On discharge, patients are provided with contact details should they have any post operative problems and receive a post discharge phone call within 48 hrs of discharge.

Patient experience – informing patient choice •

Increasing the use of Patient Reported Outcomes Studies (PROMs) – Clifton Park NHS Treatment Centre uses the National PROMS results for hip and knee replacements. These are used to gain a better understanding of treatment outcomes from a patient point of view. Results are shared with Consultants at our Clinical Governance meetings. All members of the multidisciplinary team are encouraged to review the PROMs outcomes and changes made as required to improve the patient experience. Currently compared to National compliance rate of submitting completed consent forms Clifton Park is above in knees and below in hips therefore this will be a priority in 2012/13 to increase the hip compliance rate to at least the national rate.

•

Patient experience – personal needs. This is a mandatory section of Quality Requirements and Nationally Specified Events (CQUIN) that we are required to report on. This will look at 5 questions, each describes a different element of the overarching theme: “responsiveness to personal needs: • • •

Involved in decisions about treatment/care Hospital staff available to talk about worries/concerns Privacy when discussing condition/treatment

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• •

Informed about medication side effects Informed who to contact if worried about condition after leaving hospital

The indicator incorporates questions which are known to be important to patients and where past data indicates significant room for improvement across England. Reference: DH 2010 Using the Commissioning for Quality and Innovation (CQUIN) payment framework - Guidance on national goals for 2011/12 (page 22). Data will be sourced from the Adult inpatient survey from the CQC nationally coordinated patient survey programme. The survey is conducted annually between October and January for patients who had an inpatient episode between July and August. •

Efficient service for patients. A very comprehensive Blood Transfusion Service continues to be provided by York Trust Hospital under a Service Level Agreement.

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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 Clifton Park NHS Treatment Centre provided Elective Orthopaedic NHS services. Clifton Park NHS Treatment Centre continually reviews all the data available to them on the quality of care provided. The income generated by the NHS services reviewed from 1 April 2011 to 31 March 2012 represents approximately 95% per cent of the total income generated from the provision of NHS services by Clifton Park NHS Treatment Centre during this period. 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 a % of Total Nursing hours is 21.2% Agency Hours as % of Total Hours is 0.5% 7.8% Staff Turnover 3.20% Sickness Mandatory Training = 85% completed in last 12 months Number of Significant Staff Injuries = 0 Appraisals = 87% completed in last 12 months

Ramsay participated in the Times 100 staff satisfaction survey. 1637 surveys were returned which was a 40.7% response rate. Ramsay Healthcare Score was 608.7 on a 1000 point scale and was classed as ‘ones to watch’. Clifton Park’s response rate was 47%.

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Following this survey a local hospital team is formed and an action plan developed to improve staff satisfaction.

North Region Overall Leadership My Company My Manager My Team Personal Growth Fair Deal Giving Back Wellbeing

Clifton Park 4.69 4.62 5.27 4.84 5.22 4.76 3.97 4.13 4.69

4.86 4.70 5.30 4.94 5.32 4.74 4.44 4.29 5.19

Patients 12 x Formal complaints 1st April 2011 to 31st March 2012 = 0.41% 94.6% Patient Satisfaction Score Significant reportable incidents during 2011 = 0% 5 Readmissions patients in 2011 = 1.7 readmissions per 1000 Admissions 0 EMSA (Eliminating Mixed Sex Accommodation) breaches

Quality A comprehensive Health, Safety and Facilities audit is carried out annually. This internal audit returned a score of 94% compliance and an action plan has been developed to correct the key areas identified. (2011 score 86%). A Disability Discrimination Act audit was carried out in March 2011. Our overall Infection Control Audit score is 97.5%.

2.2.2 Participation in Clinical Audit During 1 April 2011 to 31 March 2012, five national clinical audits and National Confidential Enquiries covered NHS services that Clifton Park NHS Treatment Centre provides.

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The national clinical audits and national confidential enquiries that Clifton Park NHS Treatment Centre was eligible to participate in during 1 April 2011 to 31March 2012 are as follows:

National Clinical Audits and National Confidential Enquiries (NA = not applicable to the services provided) For information/reports on audits participated in please go to the following link: http://www.hqip.org.uk/ncas-for-qa-introduction/ Name of Audit

Participation

Peri-and Neo-natal Children Paediatric pneumonia (British Thoracic Society) Paediatric asthma (British Thoracic Society) Pain management (College of Emergency Medicine) Childhood epilepsy (RCPH National Childhood Epilepsy Audit) Paediatric intensive care (PICANet) Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) Diabetes (RCPH National Paediatric Diabetes Audit) Acute care Emergency use of oxygen (British Thoracic Society) Adult community acquired pneumonia (British Thoracic Society) Non invasive ventilation -adults (British Thoracic Society) Pleural procedures (British Thoracic Society) Cardiac arrest (National Cardiac Arrest Audit) Severe sepsis & septic shock (College of Emergency Medicine) Adult critical care (ICNARC CMPD) Potential donor audit (NHS Blood & Transplant) Seizure management (National Audit of Seizure Management) Long term conditions Diabetes (National Adult Diabetes Audit) Heavy menstrual bleeding (RCOG National Audit of HMB) Chronic pain (National Pain Audit) Ulcerative colitis & Crohn's disease (UK IBD Audit) Parkinson's disease (National Parkinson's Audit) Adult asthma (British Thoracic Society) Bronchiectasis (British Thoracic Society) Elective procedures Hip, knee and ankle replacements (National Joint Registry) Elective surgery (National PROMs Programme) Intra-thoracic transplantation (NHSBT UK Transplant Registry) Liver transplantation (NHSBT UK Transplant Registry) Coronary angioplasty (NICOR Adult cardiac interventions audit) Peripheral vascular surgery (VSGBI Vascular Surgery Database) Carotid interventions (Carotid Intervention Audit) CABG and valvular surgery (Adult cardiac surgery audit) Cardiovascular disease Acute Myocardial Infarction & other ACS (MINAP) Heart failure (Heart Failure Audit) Acute stroke (SINAP) Cardiac arrhythmia (Cardiac Rhythm Management Audit)

N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service

% cases submitted

N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service YES N/A – no service N/A – no service N/A – no service N/A – no service

0%

N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service YES YES N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service

100% 100%

N/A – no service N/A – no service N/A – no service N/A – no service

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Name of Audit Renal disease Renal replacement therapy (Renal Registry) Renal transplantation (NHSBT UK Transplant Registry) Cancer Lung cancer (National Lung Cancer Audit) Bowel cancer (National Bowel Cancer Audit Programme) Head & neck cancer (DAHNO) Oesophago-gastric cancer (National O-G Cancer Audit) Trauma Hip fracture (National Hip Fracture Database) Severe trauma (Trauma Audit & Research Network) Psychological conditions Blood transfusion Bedside transfusion (National Comparative Audit of Blood Transfusion) Medical use of blood (National Comparative Audit of Blood Transfusion) Health promotion Risk factors (National Health Promotion in Hospitals Audit) End of life Care of dying in hospital (NCDAH) Additional Audits National Surveillance Programme (HPA) PEAT

Participation

% cases submitted

N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service N/A – no service

N/A – no service Insufficient Patients N/A – no service

N/A – no service

YES YES

100% N/A

The reports of five national clinical audits from 1 April 2011 to 31 March 2012 were reviewed by the Clinical Governance Committee at Clifton Park NHS Treatment Centre.

Local Audits Clifton Park NHS Treatment Centre participates in the Ramsay Corporate Audit programme (the schedule can be found in appendix 2) all of which go through the Clinical Governance Committee and actions taken recorded to improve the quality of the healthcare provided. The following actions were indicated by the outcomes of the following audits (based on a random selection of 10 sets of patients’ medical records) that fell below 90%: •

The Deteriorating Patient: scored only 81% Sept 2011 due to not all staff completing new AIM training. Training was completed and repeat audit in March 2012 indicated an improved score of 93%.

•

Surgical Site Infection Prevention: scored 83% November 2011, as although Patients body temperature was maintained above 36 degrees in the perioperative period this was not documented, a repeat audit in February 2012 indicated an improvement to 90%.

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•

Physiotherapy records: scored 89% March 2012 due to failure to complete all details in documentation, an action plan has been put in place to address this and audit to be repeated.

2.2.3 Participation in Research Corporate Clinical Governance granted permission for Clifton Park NHS Treatment Centre to participate into Ethics Committee Approved research of “A Prospective, Non Comparative, Multicentre, Multinational Study to Determine the Performance & Survivorship of the Sigma HP Partial Knee System” This is due to commence June 11th 2012. We also obtain consent from patients to donate bone samples to York University to aid their research into osteoporosis this has been approved by research ethics committee.

2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Clifton Park’s income from 1 April 2011 to 31st March 2012 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. See Appendix 2 for our Schedule.

2.2.5 Statement from the Care Quality Commission (CQC) Clifton Park NHS Treatment Centre is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions. An unannounced inspection of Clifton Park Treatment Centre was undertaken in February 2012 and all standards were met with full compliance. The Care Quality Commission has not taken enforcement action against Clifton Park NHS Treatment Centre during 2011/12. Clifton Park NHS Treatment Centre has not participated in any special reviews or investigations by the CQC during the reporting period.

2.2.6 Data Quality Data Quality is taken very seriously at Clifton Park NHS Treatment Centre. The quality of our data, whether this is in the form of local audits, paper records, or data submitted to the DoH or PCTs, reflects directly on the quality of the services provided at the hospital.

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As part of our Standard Acute Contract, we are required to demonstrate that we monitor and improve data, to support care quality. This is undertaken through our Clinical Audit programme, part of our audit programme covers medical records and anaesthetic records audits ensuring that key information is recorded throughout the patient journey. The actions required for each audit are documented and discussed at various hospital committee meetings. Audit results for anaesthetic records: Audit Anaesthetic records

Feb 2011 98%

Aug 2011 99%

Feb 2012 94%

July 2011 99%

Nov 2011 100%

Audit results for medical records audit: Audit Medical records audit

Feb 2011 99%

Feb 2012 98%

Secondary Uses Service (SUS) submissions - Since the commencement of the Standard Acute Contract, Clifton Park’s SUS submissions have been improving month-on-month during the period April 11 – March 12 Clifton Parks submission were 100% This is directly attributable to the hospital’s dedicated data quality team who work alongside all departments in the hospital to ensure that all data is entered correctly and also the suite of reporting tools available through Ramsay’s corporate IS team.

NHS Number and General Medical Practice Code Validity Clifton Park NHS Treatment Centre submitted records during 2011/12 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included: The patient’s valid NHS number was: 100% for admitted patient care; 100% for outpatient care; and 0% for accident and emergency care (not undertaken at our hospital).

The General Medical Practice Code was: 100% for admitted patient care; 100% for outpatient care; and 0% for accident and emergency care (not undertaken at our hospital).

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Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2011/12 was 77% and was graded ‘green’ (satisfactory).

Clinical coding error rate Clifton Park NHS Treatment Centre was not subject to the Payment by Results clinical coding audit during 2011/12 carried out by the Audit Commission. Clifton Park NHS Treatment Centre employs a Clinical Coder who has undertaken the Connecting for Health Clinical Coding Foundation Course in 2011 and is responsible for all diagnostic and procedure coding and is actively involved in audit processes.

2.2.7 Stakeholders views on 2011/12 Quality Account Copies of this quality account for comment prior to publication have been sent to: Involvement Network (LINk) Overview and Scrutiny Committee (OSC) Lead commissioning primary care trust (PCT) Comments received are published below:

NHS North Yorkshire and York is the lead Commissioner for Clifton Park NHS Treatment Centre and we are pleased to be able to review and comment on their Quality Account for 2011/12, in conjunction with our Associate Commissioner, NHS East Riding of Yorkshire. Over the past 12 months we have worked together as Commissioners and Providers to improve the quality of orthopaedic health care services for the residents of York and the East Riding. Through the contract management process, Clifton Park NHS Treatment Centre has provided evidence to us as Commissioners, by sharing a breadth of data and quality metrics which has assured us of the quality of patient services. The Quality Account for Clifton Park NHS Treatment Centre provides an accurate and honest account of the quality of patient care provided. We are especially pleased to note the following achievements:• • •

94.6% Patient Satisfaction Score - Clifton Park NHS Treatment centre consistently achieves high patient satisfaction scores and, by studying the results, constantly seek ways to further improve the patient experience. Nil EMSA (Eliminating Mixed Sex Accommodation) breaches. No Serious Incidents reported in 2011.

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• • •

94% compliance for the Health & Safety Audit 2012 (2011 score 86%) An unannounced inspection of Clifton Park Treatment Centre was undertaken in February 2012 and all standards were met with full compliance. 87% of staff appraisals completed in last 12 months. The priorities detailed in the Quality Account for 2012/13 clearly identify the three elements of quality i.e. patient safety, clinical effectiveness and patient experience.

• • • •

NHS Safety Thermometer – a monthly 24 hours prevalence audit. Introduction on a new Pathology service with the ability to access electronic reports immediately ensuring an efficient service for patients. VTE risk assessment is carried out on all admitted surgical patients. Pain Control – patients have the right to care that promotes comfort and minimizes pain.

As a commissioner we commend this Quality Account for its accuracy, honesty, and openness in its performance assessment. We recognise that Clifton Park NHS Treatment Centre is a top performing hospital and we would like to congratulate them on their many quality achievements in 2011/12 and look forward to working collaboratively with the organisation in 2012/13.

Julie Bolus Director of Nursing NHS North Yorkshire and York

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York LINk Holgate Villa 22 Holgate Road York YO24 4AB

Gwenn Mather Clifton Park Treatment Centre Bluebeck Drive Shipton Road YO30 5RA 28thth June 2012

Dear Ms Mather Clifton Park Treatment Centre Quality Accounts 2011– 2012 Thank you for giving York LINk the opportunity to comment on your Quality Accounts for 2011-2012. We were impressed with the ‘Welcome to’ section and description of the unit and its facilities at the beginning of the document which provided clear details about the services offered at the Centre. Most of the account was easy to read and understand – we were pleased to see that you use actual numbers as well as percentages in some of the graphs. However, the Audit Programme table was quite difficult to interpret. We feel that the inclusion of a glossary of terms and abbreviations would make the document even more accessible. We are very pleased to see that you have a wide variety of methods for obtaining patient feedback, and that you are committed to using patients’ experiences to inform service development. During the coming year, if there is any way you feel that the LINk could be of assistance to you in improving or enhancing your patients’ experience, please do not hesitate to get in touch. Yours sincerely

Mrs Lesley Pratt Chair, York LINk

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Part 3 Statements of quality delivery Matron, Gwenn Mather 3.0 Review of quality performance 1 April 2011 - 31 March 2012 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:

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• • • • • •

Infrastructure Culture Quality methods Poor performance Risk avoidance Coherence

Ramsay Health Care Clinical Governance Framework

The Matron at Clifton Park NHS Treatment Centre actively promotes clinical governance and collaborates with NHS partners to ensure that Clifton Park NHS Treatment Centre is informed of relevant initiatives to continually improve the safety and excellence of the services offered. Matron attends a number of district meetings to nurture relationships with key stakeholders/NHS/PCTs these include – Quality Performance Group, Deprivation of Liberty Group; Local Intelligence Network for Controlled Drugs group.

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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). Clifton Park NHS Treatment Centre 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 Clifton Park NHS Treatment Centre is a progressive hospital focussed on improving its performance every year, particularly with regard to 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 demonstrated below:

3.1.1 Infection prevention and control Clifton Park NHS Treatment Centre has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 6 years. We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia, Clostridium difficile and E coli infections with a programme to reduce incidents year on year. Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and Clifton Park NHS Treatment Centre remains below the lowest percentile for infection rates. 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. Clifton Park NHS Treatment Centre has its own Infection Control Link Nurse and IPCC is included in our Clinical Governance agenda.

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Programmes and activities within our hospital include: • • • •

All staff undertake mandatory annual infection prevention and control training Infection Control Audit In–house training i.e. hand washing Healthcare associated infections (HCAI) are acquired as a result of healthcare intervention. High standards of Infection Prevention and Control practice minimise the risk of occurrence and as can be seen from the bar chart below Clifton Park Treatment Centre has had a low HCAI rate annually for the past 2 years and is well below the National Average of 28%.

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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. The graph below shows our PEAT scores over the last 3 years. The latest result indicates improved scoring following the implementation of the redecorating programme demonstrating the improvement to the hospital environment. PEAT audit results 2011 - 2012 100% 90% 80% 70% 60% 50%

99%

99.20%

2011

2012

40% 30% 20% 10% 0%

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. Staff at Clifton Park NHS Treatment Centre have a high awareness of safety which has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. 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 as soon as received 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 Managers who ensure we keep up to date with all safety issues.

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Adverse Incidents and near misses reported at Clifton Park Treatment Centre: • • •

2010 = 14.5 per 1000 admits 2011 = 12.5 per 1000 admits (to March 31st) 2012 = 7.6 per 1000 admits (to March 31st)

The incidents reported include patients, visitors, staff and sub-contractors who utilise and access the Treatment Centre. The above figures indicate that we encourage the reporting of all incidents no matter how minor, reflecting a raised awareness of the importance of safety in the workplace.

3.2 Clinical effectiveness Clifton Park NHS Treatment Centre has a Clinical Governance team and committee that meet regularly through the year to monitor quality and effectiveness of care. Key performance indicators, clinical incidents and complaints, patient and staff feedback, training and development and infection control 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.

3.2.1 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.

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As can be seen in the above graphs our return to theatre rate remains very low. These figures are constantly monitored throughout the year via our clinical governance and medical advisory committee framework.

3.2.2 Readmission to hospital Monitoring rates of re-admission 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.

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As can be seen in the above graphs our readmission to hospital rate has changed little over the last 2 years. These figures are constantly monitored throughout the year via our clinical governance and medical advisory committee framework.

3.3 Patient experience All feedback from patients regarding their experiences at Clifton Park NHS Treatment Centre 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 on

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notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. All negative comments or suggestions for improvement are also communicated 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 fed back 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 DoH bodies occurs as required and according to Ramsay and DoH policy. Feedback regarding the patient’s experience is encouraged in various ways via: ƒ ƒ ƒ ƒ ƒ ƒ

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 PROMs surveys Care pathways – patients 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 Clifton Park NHS Treatment Centre. To record a satisfaction index over 92%, 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%.

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Patient Satisfaction Levels Q1 2011 v Q1 2012 100.00% 90.00% 80.00% 70.00% 60.00% 50.00%

93.70%

94.60%

Q1 2011

Q1 2012

40.00% 30.00% 20.00% 10.00% 0.00%

As can be seen in the above graph our Patient Satisfaction rate increased from 93.7% in Q1 of 2011 Jan – Mar, to 94.6% in Quarter 1 2012. Clifton Park NHS Treatment Centre rates in the top 2-3% of organisations. From the patient satisfaction survey it is possible to identify both areas for improvement as well as areas where we excel. Following the publication and communication of the results an action plan is developed.

Examples of areas for improvement: Enough explanation of medicines given before discharge 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 90.6%

95.9%

40.0% 30.0% 20.0% 10.0% 0.0% Q1 2011

Q1 2012

Having being previously identified as an area for improvement this result shows an improvement due to actions taken to includes additional written information regarding possible side effects to be provided to all patients. An explanation of medication given has also been added to our discharge checklist. Plus the introduction of booklets “Managing your pain after your Operation”.

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Satisfaction with cleanliness 100% 90% 80% 70% 60% 50%

97%

99.0%

2011

2012

40% 30% 20% 10% 0%

The latest results show a higher score than in the previous quarter, following a review of services with the Housekeeping team.

3.3.2 Patient Reported Outcome Measures (PROMs) Clifton Park NHS Treatment Centre participates in the Department of Health’s PROMs surveys for hip and knee surgery for NHS and Private patients. The graph below shows the PROMs data for NHS patients from May 2009 to April 2012. Hip replacement patients

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Knee Replacement Patients

Access to Clifton Park NHS Treatment Centre and Ramsay’s PROMs results can be found at the following website: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category

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3.4 Clifton Park NHS Treatment Centre Case Study Acute Post-Operative Pain Management in Adults Background Statement Pain management is understood to be a fundamental human right and integral to the ethical, patient-centred and cost-effective practice of modern medicine: Acute Pain Management (Scientific Evidence Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine 2010). Clifton Park NHS Treatment Centre will take into account NICE and other best practice guidance, and will attempt to reduce existing variations in practice ensuring universal standards of care for patients wherever they access our services. Patients have the right to care that promotes comfort and minimises pain. To this end, Clifton Park NHS Treatment Centre will provide a responsive and competent service that monitors and improves all aspects of acute post operative pain management. In order to comply with this statement, in 2010, Ramsay Corporate Office initiated the development of an Acute Pain Management Policy for use in Ramsay sites throughout the UK. As Recovery Lead, and in view of extensive experience in the field of Pain Management, Staff Nurse (SN) Patricia Noble, was invited to be a member of the team developing this policy. Early in 2011, Clifton Park was one of two sites which piloted the policy. The results of the pilot were very encouraging. The policy was approved and launched in June 2011.

Initial Actions •

Prior to the launch of the policy, training sessions were held for both Recovery and Ward staff. In view of the fact that Clifton Park had already piloted the policy, this was very much an update on the policy.

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•

SN Noble regularly monitors the effectiveness of pain management at Clifton Park NHS Treatment Centre and, in December 2011, carried out an audit of compliance. The results of the audit were very positive with the only shortfall being in the provision of written information given to the patient in relation to the drugs they were given on discharge. This shortfall was owing to corporate production problems with the leaflet, which has now been resolved.

Further actions • • •

SN Noble now leads regular training sessions on Pain Management for all staff; this includes the Pain Management section of the AIMS course. SN Noble has been identified as the Pain Management Lead at Clifton Park NHS Treatment Centre, with continued liaison with all disciplines involved in Acute Pain Management. Additionally, the hospital also utilises the information leaflet “Managing your pain after your operation“(see appendix 3). This is proving to be very useful to both staff and, ultimately, the patient.

Update •

In the Ramsay Health Care UK Patient Experience Survey of Private and NHS patients for Quarter 4 2011, Clifton Park scored a rating of 100% satisfaction to the statements: “Everything possible done to control pain” “Everything possible done to control nausea/vomiting”

•

Following an initial mini audit of pain management in shoulder surgery, Mr S Boyle (Consultant Shoulder Surgeon) and SN Noble are looking to conduct a more intensive audit of post–operative pain management in shoulder surgery.

•

The use of Oxycodone has recently been added to the pain management medication administered at Clifton Park, with initial results being quite positive.

The team at Clifton Park NHS Treatment Centre, through regular updates and training in new innovations in Pain Management, will continue to deliver a safe, high quality service through the implementation, review and improvement of standards that determine effective acute pain management; in collaboration with patients, clinicians, and managers.

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Appendix 1 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.

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Appendix 2 – CQUIN Schedule Goals and Indicators National and Regional Goal no.

Description of goal

Quality Domain(s)

Indicator number

Indicator name

National or Regional indicator

1

Reduce avoidable death, disability and chronic ill health from Venousthromboembolism (VTE)

Safety

1

VTE risk assessment

Nationally mandated

2

Improve responsiveness to personal needs of patients

Patient Experience

2

Composite indicator on responsiveness to personal needs from the Adult Inpatient Survey

Nationally mandated

3

Reduction in post operative infection rates, reduce use of unnecessary antibiotics, lower rates of Venus Thrombosis

Patient Safety

3

Hip and knee replacement best practice bundle

Regional

Improve the focus on the care of the patients, in line with Essence of Care. Use of validated nutritional indicator screening tool will be encouraged to reduce rates of malnutrition and associated adverse outcomes

Patient Safety

4

Care and Compassion – Nutritional screening

Regional

Improvement in pressure ulcer prevention and management in line with essence of care

Patient Safety

5

Care and Compassion – Improvement of Pressure Ulcers

Regional

4

5

Effectiveness

Patient Experience

Indicator weighting

Effectiveness

Patient Experience Effectiveness

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Goals and Indicators Local Goal no.

Description of goal

Quality Domain(s)

Indicator number

Indicator name

National or Regional indicator

6

Protection from infection

Patient Safety

6

To reduce % of number of hospital acquired UTI’s from indwelling catherisation.

Local

7

Improve the identification of deterioration in condition

Local

Patient Experience

Indicator weighting

Clinical Effectiveness 7

Reduce the degree of harm through improved identification and response to a deterioration in condition

Patient Safety Patient Experience

Improve the response to identified deterioration in condition

Clinical Effectiveness

To reduce % of number of crash calls To increase number of rapid response calls per month To increase the % of patients who triggered that received an appropriate response 8

Secure safe, high quality, coordinated care focused on hospital discharge arrangements

Patient Safety Patient Experience Clinical Effectiveness

8

Help to ensure safe discharge procedures and any unnecessary delays in discharge or potential grounds for re-admission

Local

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Detail of Indicator (to be completed for each indicator) Indicator 1 – VTE risk assessment % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the national tool

Description of indicator Numerator

Number of adult inpatient admissions reported as having had a VTE risk assessment on admission to hospital using the national tool

Denominator

Number of adults who were admitted as inpatients (includes day cases, maternity and transfers; both elective and non-elective admissions) VTE is a significant patient safety issue, however outcome data on VTE is poor – post mortem studies suggest that only 1-2 in every 10 fatal pulmonary emboli is diagnosed. Whilst work is underway to improve reliability of outcome data, the process measure of VTE risk assessment will set an effective foundation for appropriate prophylaxis. This gives the potential to save thousands of lives each year.

Rationale for inclusion

Data source collection Organisation collection

and

frequency

responsible

Frequency of Commissioner

of

Monthly return through Unify

for

data

Provider

reporting

to

Monthly

Baseline period / date

Quarter 1

Baseline value Final indicator period / date (on which payment is based)

Quarter 4

Final indicator threshold)

90% achievement required

value

Final indicator reporting date

(payment

0.15% of National 0.3% Quarter 4

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Indicator 2 – Composite indicator on responsiveness to personal needs The indicator will be a composite, calculated from 5 survey questions. Each describes a different element “responsiveness to personal needs :

of

the

overarching

theme:

Description of indicator

• Involved in decisions about treatment/care • Hospital staff available to talk about worries/concerns • Privacy when discussing condition/treatment • Informed about medication side effects • Informed who to contact if worried about condition after leaving hospital

Numerator

Index-based score reflecting positive responses to the 5 questions within the composite indicator

Denominator

N/A

Rationale for inclusion

The indicator incorporates questions which are known to be important to patients and where past data indicates significant room for improvement across England.

Data source collection Organisation collection

and

frequency

responsible

Frequency of Commissioner

of

for

data

reporting

to

Adult inpatient survey, from the CQC nationally coordinated patient survey programme. The survey is conducted annually between October and January for patients who had an inpatient episode between July and August. Provider

Annually: 1) Early local data (mid-January 2011) 2) Published data. (April-May 2011)

Baseline period / date

Adult inpatient survey 20010/11 (based on inpatient episodes between October and March 2011)

Baseline value

To be confirmed

Final indicator period / date (on which payment is based)

Adult inpatient survey 2010/11 (based on inpatient episodes between July and August 2010)

Final indicator threshold)

To be agreed

value

Final indicator reporting date

(payment

To be confirmed

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Detail of Indicator 3 – Hip and Knee Description of indicator Denominator 1

Hip and knee replacement best practice bundle Total number of hip or knee replacements carried out in the quarter (If sampling has been used for this indicator then provide details of how a random sample has been taken to provide representative data for hip or knee replacement patients)

Denominator 2

Denominator 2 is the size of random sample of (Denominator 1) taken during the quarter. (if sampling has not been used Denominator 2 = Denominator 1)

Numerator 1

Number of these (Denominator 2) receiving prophylactic antibiotic within 1 hour prior to surgical incision (Measure 45)

Numerator 2

Total number of (Denominator 2) excluded from Measure 45

Numerator 3

Number of (Denominator 2) where Measure 45 is not known and patient not excluded

Numerator 4

Number of these (Denominator 2) where prophylactic antibiotics are discontinued within 24 Hours after surgery end time (Measure 47)

Numerator 5

Number of (Denominator 2) excluded from Measure 47

Numerator 6

Number of (Denominator 2) where Measure 47 is not known and patient not excluded

Numerator 7

Number of these (Denominator 2) who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery (Measure 49)

Numerator 8

Number of (Denominator 2) excluded from Measure 49

Numerator 9

Number of (Denominator 2) where Measure 49 is not known and patient not excluded

Rationale for inclusion

Reduced postoperative infection rates, reduce use of unnecessary antibiotics, lower rates of Venous Thromboembolism

Data source and frequency of collection

Provider Quarterly returns

Organisation responsible for data collection

Provider

Frequency of reporting to commissioner

At end of each quarter

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Baseline period / date

2009/10 outturn

Baseline value Final indicator period / date (on which payment is based)

Quarter 4

Final indicator value (payment threshold)

0.042 of the Regional 0.5%

Final indicator reporting date

Quarter 4

Rules for partial achievement of indicator at year-end Rules for any agreed in-year milestones that result in payment

Trusts are expected to have at least 95% compliance with all elements of the best practice bundle to achieve payment

Rules for delayed achievement against final indicator period/date and/or in-year milestones

Detail of Indicator 4 – Nutrition Description of indicator

Care and Compassion – Nutritional

Denominator 1

By ward and by age band 18-64 and 65+: The number of patients admitted and remaining for more than 48 hours during the quarter

Numerator 1

(i) By ward and by age band 18-64 and 65+: The number of admitted patients who underwent nutritional screening at admission (ii)By ward and by age band 18-64 and 65+: The number of patients (of Numerator 1) where appropriate action was followed, in accordance with essence of care, after screening

Denominator 2

By ward and by age band 18-64 and 65+: The number of patients discharged during the quarter

Numerator 2

(i) By ward and by age band 18-64 and 65+: The number of patients undergoing nutritional screening prior to discharge (ii) By ward and by age band 18-64 and 65+: The number of admitted patients (of Numerator 2i) who were at ‘High’* nutritional risk at discharge (iii) By ward and by age band 18-64 and 65+: The number of patients assessed as ‘high’ nutritional risk with appropriate referrals/continuing care plans in place

Numerator 3

Delivery of essence of care Action plan to be agreed by commissioner Trust to ensure that there is an action plan in place which demonstrates

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how the following indicators will be met to best practice standards in “Essence of Care”pp51-64 DH June 2009 1. Screening and assessment 2. Planning, implementation, evaluation and revision of care 3. Monitoring 4. Environment 5. Assistance

People receive the care and assistance they require with eating and drinking

6. Information

People and carers have sufficient information to enable them to obtain their food and drink People are provided with food and drink that meets their individual needs and preferences

7. Provision

Rationale for inclusion

People who are screened on initial contact and identified at risk receive a full nutritional assessment People's care is planned, implemented, continuously evaluated and revised to meet individual needs and preferences for food and drink People's food and drink intake is monitored and recorded People feel the environment is conducive to eating and drinking

8. Availability

People can access food and drink at any time according to their needs and preferences

9. Presentation

People's food and drink are presented in a way that is appealing to them

10. Promoting People are encouraged to eat health Improved focus on the care of the patients. Use of a validated nutritional indicator screening tool will be encouraged to reduce rates of malnutrition and associated adverse outcomes.

Data source and frequency of collection

Provider quarterly

Organisation responsible for data collection

Provider

Quarter 1 - submit data (baseline) Frequency of reporting to commissioner

Quarter 2 – submit data and submit agreed Action plan Quarter 3 – submit data Quarter 4 – submit data showing achievement against baselines showing improvement against each numerator.

Baseline period / date

Quarter 1

Baseline value

Action plan must be approved by commissioner and progress reported quarterly

Final indicator period / date (on which payment is based)

Quarter 4

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Final indicator value (payment threshold)

0.042 of the Regional 0.5%

Final indicator reporting date

Quarter 4

Rules for partial achievement of indicator at year-end Submission of Action plan Rules for any agreed in-year milestones that result in payment

Providers must agree their evidence based tool with their PCT commissioner accordingly. Rules for delayed achievement against final indicator period/date and/or in-year milestones

The data on malnutrition will only be required from PCT Providers with bedded areas. If trusts change their validated nutritional indicator screening tool they must then agree this with commissioners before re-submitting.

Additional Information

“High” risk is defined as MUST - Score 2 and above(or equivalent if a different screening tool is used)

Detail of Indicator 5 – Pressure Ulcers Description of indicator

Inpatients experience care that maintains or improves the condition of their skin and underlying tissues for all ages

Denominator 1

Submitted as Denominator 1 in Indicator 13

Numerator 1

Total number of patients (of Denominator 1) who have one or more existing pressure ulcers on admission of Grade II and above.

Numerator 2

The number of incident forms completed for grade II ulcers and above

Numerator 3

The number patients with one or more pressure ulcers, with the highest ulcer having NICE Trigger Grading II

Numerator 4

The number patients with one or more pressure ulcers, with the highest ulcer having NICE Trigger Grading III

Numerator 5

The number patients with one or more pressure ulcers, with the highest ulcer having NICE Trigger Grading IV

Numerator 6

The number of root cause analysis investigations undertaken for patients with NICE Grade III pressure ulcers

Numerator 7

Number of patients acquiring a pressure ulcer within 10 days of admission

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Numerator 8

Rationale for inclusion

Ensure an action plan is in place which demonstrates how the following indicators will be met to best practice standards in “Essence of Care”pp75-84 DH June 2009

Factor

Best practice

1. Screening and Assessment

People who are screened on initial contact and identified at risk of developing pressure ulcers receive a full assessment of their risk

2. Information

People and carers have ongoing access to evidence-based information concerning pressure ulcer prevention and management

3. Planning, implementation, evaluation and revision of care

People's care is planned, implemented, continuously evaluated and revised to meet their individual needs and preferences concerning pressure ulcer prevention and management

4. Prevention repositioning

People are repositioned to reduce the risk, and manage the care, of pressure ulcers

5. Prevention pressure redistribution

People are cared for on pressure redistributing support surfaces to reduce the risk, and manage the care, of pressure ulcers

6. Prevention resources and equipment

People have the resources and equipment required to reduce the risk, and manage the care, of pressure ulcers

Improve pressure ulcer prevention and management.

Data source and frequency of collection

Quarterly

Organisation responsible for data collection

Provider

Frequency of reporting to commissioner

Quarterly

Baseline period / date

Quarter 1

Baseline value

Action plan must be approved by commissioner and progress reported quarterly

Final indicator period / date (on which payment is based)

Action Plan must be approved by the commissioner and then progress reported at Quarter 4

Final indicator value (payment threshold)

0.042 of the Regional 0.5%

Final indicator reporting date

Quarter 4

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Rules for partial achievement of indicator at year-end (i) Providers must reduce the grading of pressure ulcers setting a downward trajectory for NICE Grade III and above, agreed locally.

Rules for any agreed in-year milestones that result in payment

(ii) Providers must also have 100% root cause analysis of pressure ulcers with NICE Triggers Grading III and above. (iii) Providers must submit Action Plans detailing delivery of Essence of Care by end of Quarter 2. (iv) Payment will be based on (i),(ii) and (iii) all being achieved

Rules for delayed achievement against final indicator period/date and/or in-year milestones

Detail of Indicator 6 – Infection Description of indicator

To reduce % of number of hospital acquired UTI’s from indwelling catherisation.

Numerator

Number of patients who have a hospital acquired UTI

Denominator

All patients who have indwelling catheter inserted throughout hospital stay including all specialities both elective and non elective Urinary Tract Infections (UTI) are the second largest single group of healthcare associated infections in the UK and make up 20% of all hospital acquired infections. UTI’s lead to longer stays in hospital for patients and for pregnant women the development of a UTI can be especially problematic leading to pre-term delivery, anaemia and a low birth weight baby.

Rationale for inclusion

UTIs have been found to extend the average length of hospital stay by 6 days, and UTIs may account for an extra 798,000 bed days annually. It has been estimated that the 1994/95 costs of treating UTIs in the NHS were in the order of £124 million, a reduction in UTIs through improved monitoring and management in an attempt to prevent unnecessary catheterisation, prompt daily review of patients with catheter and removal of catheter ASAP would provide better standards and quality of care, reduction in healthcare associated infections and prevention of costs for treating catheter associated urinary tract infections. 80% of UTIs occurring in hospital can be traced to indwelling urinary catheters and lead to longer length of

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stay in hospital (average 6 days longer) Quarter One Agree % decrease from baseline data collected in quarter one of all patients who have catheter inserted during their hospital stay. Data source and frequency of collection

Quarter Two, three and four Receive data which demonstrates % decrease in number of acquired UTI’s following catherisation. Receive at end of each quarter action plan demonstrating work being undertaken to decrease number.

Organisation responsible for data collection

Acute provider Community provider

Frequency of reporting to commissioner

End of each quarter

Baseline period / date

Quarter One

Baseline value

To be confirmed

Final indicator period / date (on which payment is based)

10 days after the end of quarter one

Final indicator value (payment threshold)

To be confirmed

Final indicator reporting date

10 days after March 2011

Rules for partial achievement of indicator at year-end

Not apply

Rules for any agreed in-year milestones that result in payment

To be confirmed

Rules for delayed achievement against final indicator period/date and/or in-year milestones

To be confirmed

Detail of Indicator 7 – Reduction in harm The provider will demonstrate 10% reduction in harm, through improved identification and response to deterioration in condition (for adults and children) Description of indicator

This will be achieved through Improving the identification of deterioration 1. % of patients with a complete record of observations 2. Implementation of a NICE compliant track and trigger

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system (where this is not already in place) Improving response to deterioration , including 3. No. of cardiac arrest calls per month 4. No. of rapid response calls per month 5. % of patients who triggered that received an appropriate response Number of wards where Implementation of a NICE compliant track and trigger system is in place Number of patients with a complete set of observations Improving response to deterioration , including: Numerator

•

Number of cardiac arrest calls per month

•

Number of rapid response calls per month

•

Number of patients who triggered that received an appropriate response

Agreed sample of wards Agreed sample of adults inpatients Denominator

Agreed sample of patients with a recorded trigger assessment which identified a need for an appropriate response In 2005, 66 deaths reported to the NRLS were classified as a result of failure to recognise or act upon deterioration in patient’s condition. There were a number of areas which were identified as failures in process including;

Rationale for inclusion

•

not taking appropriate observations

•

non recognition of early signs of deterioration

•

poor communication and response to observations causing concern

All of which are measures being reported under this indicator, which aims for an overall 10% reduction in harm from unrecognised or not acted upon deterioration. Further information available from http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59828 and http://www.nrls.npsa.nhs.uk/resources/?entryid45=59834

Data source and frequency of collection

Provider organisation incident reporting systems, NLRS/NPSA reporting, which should be collected and reviewed monthly. Then presented quarterly at relevant CRG Bi annual audit (reportable through the relevant Clinical Risk or Clinical Governance Group) of the measures set out in

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description of indicator Full participation in NCEPOD (available from http://www.ncepod.org.uk/about.htm) Organisation responsible for data collection

Acute

Frequency of reporting to commissioner

Please see data source and frequency of collection

Baseline period / date

Within 6 months, development of an audit protocol to support data collection for the measures set out in description of indicator

Baseline value

To be confirmed

Final indicator period / date (on which payment is based)

March 2011

Final indicator value (payment threshold)

The provider will demonstrate 10% reduction in harm, through improved identification and response, as a result of deterioration in condition

Final indicator reporting date

April 2011

Rules for partial achievement of indicator at yearend

To be agreed

Rules for any agreed in-year milestones that result in payment

To be agreed

Rules for delayed achievement against final indicator period/date and/or in-year milestones

N/A

Final indicator value (payment threshold)

To be confirmed

Final indicator reporting date

10 days after March 2011

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Detail of Indicator 8 – Secure safe, high quality, co-ordinated care focused on hospital discharge arrangements a) The Provider will demonstrate a 5% improvement in response scores to Questions 57 and 65 in the Adult National In Patient survey relating to hospital discharge arrangements

Description of indicator

b) The provider will demonstrate a 5% improvement in their top 5 areas of improvement highlighted within their Patient Experience Action Plans from the 2009 Adult Inpatient Survey and other Patient Survey data This will be achieved by •

supporting co-ordinating care planning for hospital discharge arrangements

•

ensuring that all patients are made aware of danger signals to watch for when being discharged

•

identifying and developing specific actions plans in response to the top 5 areas for improvement on patient experience

Safe, High Quality, Co-ordinate Care domain as part of the patient experience within the national adult inpatient survey. % of people responding positively to following questions: A) 5% improvement in positive responses to: Q57 – “On the day you left hospital, was your discharge delayed for any reason?’ Numerator

B) 5% improvement in positive responses to: Q65 – “Did a member of staff tell you about any danger signals you should watch for after you went homes?’ C) 5% improvement in positive responses to: The top 5 areas of improvement in patient experience, as agreed with the commissioner and reflecting data from 2009 patient survey and other benchmarked patient experience data

Denominator

2010 Inpatient Survey Data plus other agreed data sources

Rationale for inclusion

Delayed discharges contribute significantly to the efficiency of bed management and are a critical determinant of positive patient experiences for coordinated care across the health and social care economy.

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Ensure patients are aware of danger signals on discharge links to question 4 & 5 within the national patient experience CQUIN and presents extra stretch to demonstrate providers are supporting the continuum of care for adult patients discharged from hospital care. All providers are required to develop current and focused action plans on Patient Survey to secure year-on-year improvements in patient experience

Data source and frequency of collection

Agree processes on data sources over and above national patient survey data for 2010 & 2011. To be agreed at contract setting and ensuring dynamic and periodic review of progress.

Organisation responsible for data collection

Acute

Frequency of reporting to commissioner

Quarterly (unless evident concerns about performance)

Baseline period / date

To be confirmed

Baseline value

To be based upon 2010 Adult Inpatient Survey data

Final indicator period / date (on which payment is based)

September 2011

Final indicator value (payment threshold)

To be confirmed

Rules for partial achievement of indicator at year-end

To be agreed

Rules for any agreed in-year milestones that result in payment

N/A

Final indicator value (payment threshold)

To be confirmed

Final indicator reporting date

10 days after September 2011

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Appendix 3 – Managing your pain after your operation

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Quality Accounts 2011/12 Page 58 of 59

Clifton Park NHS Treatment Centre 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:

01904 464 550 www.cliftonparktreatmentcentre.co.uk

Neurological Centres

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