quality account 2018/19 · 2019-08-12 · quality accounts 2018/19 page 9 of 41 welcome to tees...

Tees Valley Hospital

Quality Account 2018/19

Contents

Introduction Page

Welcome to Ramsay Health Care UK

Introduction to our Quality Account

PART 1 – STATEMENT ON QUALITY

1.1 Statement from the Hospital Director

1.2 Hospital accountability statement

PART 2

2.1 Priorities for Improvement

2.1.1 Review of clinical priorities 2018/19 (looking back)

2.1.2 Clinical Priorities for 2019/20 (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 2019/20 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account indicators

3.2 Patient Safety

3.3 Clinical Effectiveness

3.4 Patient Experience

Appendix 1 – Services Covered by this Quality Account

Appendix 2 – Clinical Audits

Quality Accounts 2018/19 of 41

Welcome to Ramsay Health Care UK

Tees Valley Hospital is part of the Ramsay Health Care Group

The Ramsay Health Care Group was established in 1964 and has grown to

become a global hospital group operating over 100 hospitals and day surgery

facilities across Australia, the United Kingdom, Indonesia and France. Within the

UK, Ramsay Health Care is one of the leading providers of independent hospital

services in England, with a network of 31 acute hospitals.

We are also the largest private provider of surgical and diagnostics services to

the NHS in the UK. Through a variety of national and local contracts we deliver

1,000s of NHS patient episodes of care each month working seamlessly with

other healthcare providers in the locality including GPs, Clinical Commissioning

Groups


“The delivery of high quality patient care and outcomes remains the highest priority to Ramsay Health Care. Our clinical staff and consultants are critical in ensuring we achieve this across the whole organisation and we remain committed to delivering superior quality care throughout our hospitals, for every patient, every day. As a clinician I have always believed that our values and transparency are the most important elements to the delivery of safe, high quality, efficient and timely care. Ramsay Health Care’s slogan “People Caring for People” was developed over 25 years ago and has become synonymous with Ramsay Health Care and the way it operates its business. We recognise that we operate in an industry where “care” is not just a value statement, but a critical part of the way we must go about our daily operations in order to meet the expectations of our customers – our patients and our staff. Everyone across our organisation is responsible for the delivery of clinical excellence and our organisational culture ensures that the patient remains at the centre of everything we do. At Ramsay we recognise that our people, staff and doctors, are the key to our success and our teamwork is a critical part of meeting the expectations of our patients. Whilst we have an excellent record in delivering quality patient care and managing risks, the company continues to focus on global and UK improvements that will keep it at the forefront of health care delivery, such as our global work on speaking up for safety, research collaborations and outcome measurements. I am very proud of Ramsay Health Care’s reputation in the delivery of safe and quality care. It gives us pleasure to share our results with you.” Dr. Andrew Jones Chief Executive Officer Ramsay Health Care UK


Introduction to our Quality Account

This Quality Account is Tees Valley Hospitals 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.

Ramsays first Quality Account in 2010 was developed by our Corporate Office

and summarised and reviewed quality activities across every hospital and

treatment centre within the Ramsay Health Care UK. It was recognised that this

didn’t provide enough in depth information for the public and commissioners

about the quality of services within each individual hospital and how this relates to

the local community it serves. Therefore, each site within the Ramsay Group now

develops its own Quality Account, which includes some Group wide initiatives, but

also describes the many excellent local achievements and quality plans that we

would like to share.


Part 1

1.1 Statement on quality from the Hospital Director

I am delighted to introduce our Quality Account for 2018/19 which demonstrates our commitment to delivering high quality care. The report focuses upon our performance over the last year and describes our priorities for the next year. Our Vision is to be the number one choice for patients, employees and doctors. This Quality Account represents our first full year at our new facility Tees Valley Hospital and has been produced to demonstrate our continued commitment to measuring and acting on feedback from all our patients and customers about their experience, with the intention to continually learn and improve on all aspects of the services we provide. We understand that patients can be anxious about coming into hospital and that providing reassurance is very important to patients and families. This starts with patient safety, which is always our highest priority. To this end we continually review our clinical care standards, outcomes and feedback, through audit, observation and through regular open, analytical review with a ‘no blame’ approach, which helps promote a healthy learning culture. In addition we recruit, induct and train our team to enable the delivery of the highest standards in all aspects of clinical and customer care. This approach extends to family and visitors in ensuring they are made to feel welcome at Tees Valley Hospital. Tees Valley Hospital 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 preparing patients 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. Our care extends to the post discharge period, where we offer post discharge support and guidance 24 hours a day to provide ongoing reassurance. 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 and experienced doctors, nurses and other key healthcare professionals.


Our priorities for the coming year are focused upon ensuring continuous

improvement, creating services centred on the patient, getting it right first time

and putting patient safety at the heart of everything we do.

Donna Thornton, Hospital Director



1.2 Hospital Accountability Statement

To the best of my knowledge, as requested by the regulations governing the

publication of this document, the information in this report is accurate.

Donna Thornton

Hospital Director


Ramsay Health Care UK

This report has been reviewed and approved by:

Mr Martin Coady, Medical Advisory Committee Chair


Welcome to Tees Valley Hospital

Tees Valley Hospital opened in February 2018 and is a modern, purpose-built

hospital, designed for the diagnosis, assessment and treatment of conditions for

day case and in patients. We provide fast, convenient, effective and high quality

treatment for patients of all ages (excluding children below the age of 19 years),

whether medically insured, self-pay, or from the NHS).

The hospital is located within grounds of Acklam Hall, the only Grade I listed

building in Tees Valley. In 2008 the ownership of the estate was transferred to

Acklam Hall Limited who are focussing on the creation of a bespoke patient

centred health village, establishing community based healthcare, providing

surgical, medical and assessment services.

Tees Valley Hospital currently provides services for the following specialties:

dermatology, GI endoscopy, general surgery, gynaecology, oral surgery,

orthopaedics, podiatric surgery, plastic surgery and urology. Being purpose built


there is ample free car parking available, good public transport links and easy

access to main road networks.

Hospital Facilities

Welcoming reception and waiting areas to provide more appropriate space

and comfort for patients

Maximise natural light

Outpatient department with consulting rooms and treatment/ procedure

rooms

Diagnostic imaging department, including X-Ray, Ultrasound and mobile

MRI and CT

Physiotherapy Unit with individual treatment bays & a rehabilitation gym

3 ultra clean air operating theatres

Endoscopy Suite

Recovery areas with 12 day patient pods

Mary Jacques Ward: 19 in-patient beds (6 x 2 bedded bays and 7 single

rooms) all with en-suite bathrooms

Staff office accommodation

Free on-site parking

Our physiotherapy clinic is staffed with chartered, HCPC registered

physiotherapists.

Tees Valley Hospital is part of the North of England Critical Care Network and

has a Service Level Agreement in place for emergency transfer of critically ill

patients.

Tees Valley Hospital supports local charities and this year has supported

Teesside Hospice and Parkinson’s UK with staff events including bake sales and

sponsored runs.

Nursing and Medical Care

All our patients are allocated a ‘named nurse’ at the beginning of each shift, the

role of the named nurse is to provide co-ordinated care, support and treatment


which is personalised to meet individual patient needs. The named nurse

approach enables our patients to identify one nurse who is specifically and

consistently responsible for their overall nursing care. In 1992 the Department of

Health issued the Patients Charter in which the requirement for all inpatients to

have a designated ‘named nurse’ was specifically mentioned.

We have an RMO (Resident Medical Officer) who supports the Consultants and

together with the nursing team, provides round the clock medical support to all

our patients.

South Tees Clinical Commissioning Group were our lead commissioner of NHS

Services for 2018/19, on behalf of neighbouring clinical commissioning groups,

with regular service review meetings held to discuss performance. Patients were

referred and travelled from Darlington, Durham, Hartlepool, Redcar,

Middlesbrough, Stockton and North Yorkshire. NHS services are accessed direct

from GP via the electronic referral system (e-RS) and we have dedicated e-RS

Co-ordinators and a GP Liaison officer to facilitate the referral process. We hold

regular e-RS workshops at the hospital inviting medical secretaries from local GP

practices. These events give an opportunity to tour the facilities and experience

the ‘patient pathway’ first hand.

This year Tees Valley Hospital delivered 7991 patient procedures. The focus of

the hospital continues to be on delivering NHS activity equating to 97% whilst

increasing our admissions in insured or self-pay patients. In terms of workforce

there are 94 contracted members of staff employed at Tees Valley Hospital

comprising of 60% clinical posts and 40% support staff with a mix of full time and

part time positions. 61% of all clinical posts are held by registered nurses with a

nurse patient ratio of 1:6.

We have a G.P. liaison officer who works closely with the G.P.s in the

surrounding area creating a link between the community services and the

hospital.


Part 2

2.1 Quality priorities for 2018/2019

Plan for 2018/19

On an annual cycle, Tees Valley Hospital develops an operational plan to set

objectives for the year ahead.

We have a clear commitment to our private patients as well as working in

partnership with the NHS ensuring that those services commissioned to us, result

in safe, quality treatment for all NHS patients whilst they are in our care. We

constantly strive to improve clinical safety and standards by a systematic process

of governance including audit and feedback from all those experiencing our

services.

To meet these aims, we have various initiatives on going at any one time. The

priorities are determined by the hospitals Senior Management Team taking into

account patient feedback, audit results, national guidance, and the

recommendations from various hospital committees which represent all

professional and management levels.

Most importantly, we believe our priorities must drive patient safety, clinical

effectiveness and improve the experience of all people visiting our hospital.

Priorities for improvement

2.1.1 A review of clinical priorities 2018/19 (looking back)

In 2018/2019 the key principles of our clinical strategy were set around: The 5 domains of the Care Quality Commission

Safe, Effective, Caring, Responsive and Well Led care.

The values of the Ramsay Way

We are caring, progressive, enjoy our work and use a positive spirit to get

things done.

We take pride in our work and actively seek new ways of doing things

better.

We value integrity, credibility and respect for the individual.


We build constructive relationships to achieve positive outcomes for all.

We believe that success comes through recognizing the value of people

and encouraging that value through professional and personal

development.

The strategy was developed to support the transition of an existing service (Tees

Valley Treatment Centre) through development and transfer to Tees Valley

Hospital which opened in February 2018 with the ultimate aim to deliver high

quality outcomes and an excellent patient experience.

Patient Safety

A key area of focus was around reducing surgery related harm through better use of the checking process including use of the WHO Surgical Safety Checklist. We aimed to reduce risk and encourage a safer culture by improving teamwork and communication, with every team member feeling confident to speak up and raise concerns. We also wanted to see more incidents and near misses being reported, as an indicator of safety awareness.

We achieved 100% compliance with monthly WHO surgical safety audits, observational and documentation, monitored through a local CQUIN quality data indicator.

The Ramsay Health Care initiative “Speak Up For Safety” campaign facilitated through the Cognitive Institute was successfully rolled out in the hospital to both employed staff and consultants working on a practice privilege basis. Supported by governance we achieved an overall compliance rate of 90% with continued training sessions planned for new staff members. We have demonstrated excellent engagement from employed staff and consultants working on a practice privilege basis.

We held training for Heads of Department in risk management and incident reporting including effective use of Riskman the electronic reporting tool. This resulted in an increase in reporting across all department and individual users and allowing effective review and learning from incidents, trends and near misses.

We reviewed the clinical committee structure and brought it in line with the Ramsay committee structure to ensure emphasis and focus on the Clinical Governance agenda and will review in the next year the benefit of adding additional committees.

Reduce harm from unrecognised deterioration

We introduced NEWS2 in line with Ramsay revised policy for managing the deteriorating patient.

Clinical trainers were identified and they attended a training day provided by Ramsay Corporate clinical team and training was then rolled out at site level.


Sepsis and Acute Kidney Injury (AKI) have been added to the AIM training which all clinical staff complete.

There is now a Sepsis recognition flowchart in all patient pathways so this is readily available for all patients.

Flowcharts are available on all resuscitation trolleys relating to Massive Haemorrhage, Adult choking, Anaphylaxis, Anaesthetic toxicity, Asthma, Adult bradycardia, Chest pain, Fitting/ convulsions, Hypoglycaemia, Adult tachycardia and AKI assessment.

NEWS audit continues with some improvements noted and audits continue. We use NEWs documentation as part of learning from incidents with staff to demonstrate both good practice and areas for improvement.

Patient experience

Good patient experience has a positive effect on recovery and clinical outcomes, with this as a focus we committed to improving overall response rates in friends and family tests in both outpatient and inpatient/day case settings.

We introduced a customer focus group with staff representatives from all areas to ensure results and learning from feedback could be shared.

FFT results were issued to department heads monthly for sharing at team meetings and where individual recognition was detailed in patient comments these could be shared for professional development and performance review.

Whilst overall satisfaction and recommendation rates are high achieving 100% across most months the response rates remain disappointingly low in FFT and the Ramsay online patient satisfaction survey. Ramsay are testing a new feedback tool with likely roll out in late 2019 following review of findings.

We committed to improving communications to patients in relation to unexpected delays by keeping them informed and heads of department ensuring individuals are nominated each day to affect this.

The introduction of a daily huddle, a fifteen minute meeting at 8:30am where every department is represented to discuss the plans for the day, and learning from incidents, issues complaints or compliments from the previous day supports a positive patient experience.

Clinical Effectiveness

We committed to participation in applicable national audits to include data

collection for Patient Recorded Outcome Measures (PROMS) and our new data

collection for the National Joint Registry (NJR).

We began to submit data for total hip and total knee replacement PROMS in July 2018, inpatient services were not commissioned until then therefore volumes were low and health gains are not yet measurable.


We began submitting data to The National Joint Registry (NJR) following staff training; the NJR is the defined orthopaedic national clinical audit and provides the benchmark information for both the NHS and the independent sector.

Our dedicated in house physiotherapy service has supported patients to achieve realistic expectations of post-operative surgery and recovery.

We aimed to benchmark against the relevant independent sector acute providers when comparisons were available through the Private Healthcare Information Network (PHIN), as more activity is completed effective benchmarking will be undertaken.

2.1.2 Clinical Priorities for 2019/2020 (looking forward)

Tees Valleys Hospital’s Strategy for 2019/20, continues to be driven by our

commitment to ensure that quality is at the core of everything we do. As a leading

Independent Healthcare Provider we aim to continuously improve; quality, safety

and patient experience.

Our Vision is ‘to be the number one choice for patients, employees and

doctors.’ The five CQC domains will direct what we want to achieve in our

clinical strategy in 2019/2020. Under each domain we will provide clear objectives

which demonstrate our commitment to quality improvement. Evidence based

practice will underpin our objectives.

Under Safe we will focus on:

Medicines Optimisation: Helping patients to make the most of medicines

We will:

1. Further developed effective systems for the safe and secure handling of medicines, medicines procurement, the controlled introduction of new drugs etc. in accordance with current guidance. Led by our pharmacist we will ensure we have systems which are audited to ensure safe and secure handling of medicines and monitored locally through our Clinical Governance and Medical Advisory Committee.

2. All incidents will be reviewed at our Clinical Governance Committee (CGC) actions developed and improved practices shared. The CGC will review National Patient Safety Alerts (NPSA) and Medicines & Healthcare products Regulatory Agency (MHRA).

3. Every in-patient will have their medicines reconciled within 24 hours of admission in line with NICE Guidelines (NG5 2015) Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes.

4. We will complete a medicines management audit programme to evidence safe, effective administration of medications by the clinical team in line with Nursing Midwifery Council (NMC 2008) Safe Standards for Medicines Management.


The audits are:

Safe and Secure Medicines

Controlled Drugs

Prescribing / Medicines Management

Medicine Reconciliation

Medicines Missed Dose 5. We will promote a safety culture around medicines through staff training and

education. We encourage reporting of medicine related incidents through our Riskman reporting system.

6. We will deliver Medicines Management training to all staff involved and assess competency, this includes an annual ‘drug test’.

Under Effective we will focus on:

Skilled Knowledgeable Workforce. High quality, compassionate care is about

people, we want the right staff, with the right skills, in the right place at the right

time.

We recognise high quality, compassionate care is about people. Tees Valley

Hospital will do all we can to support our staff to provide high quality,

compassionate care. There has been much debate as to whether there should be

defined staffing ratios in the NHS. Jane Cummings’, Chief Nursing Officer for

England, view is that this misses the point – we want the right staff, with the right

skills, in the right place at the right time. There is no single ratio or formula that

can calculate the answers to such complex questions. With this in mind we will

ensure there is a staffing establishment which meets the needs of the services

provided and patient groups.

We will do this by:

1. Initiating the use of a ‘staffing tool’ to ensure patients dependency is accounted for when making a decision on nurse patient ratio. NICE Guidelines (SG1): Safe Staffing for Nursing in Adult In-patient Wards in Acute Hospitals (2014.) This will allow the ward manager to determine the nursing staff requirements to ensure safe patient care. The guideline will be used and recommendations about the factors that should be systematically assessed at ward level to determine the nursing staff establishment will be applied. On the day assessments of nursing staff requirements to ensure that the nursing needs of individual patients are met throughout a 24hour period will be completed.

2. Specialist / Lead nurses in: o Infection Prevention o Resuscitation o Pain Management o Wound Management


o Blood Transfusion o Occupational Health lead

To ensure patient safety and effective delivery of care that is evidenced based we

will have key lead nurses focusing on the quality elements that support nursing

care.

Our Infection Prevention Lead Nurse will ensure actions in our 2019 Infection

Prevention and Control Annual Plan are completed which evidences compliance

with requirements of the ‘Health and Social Care Act 2008 – Code of Practice for

Health and Adult Social Care on the Prevention and Control of Infections’ and

related guidance and ‘Care Quality Commission Standard Outcome 8 –

Regulation 12- Cleanliness and Infection Control’.

Our Resuscitation Lead will ensure staff training is up to date and meets the

requirements set by the UK Resuscitation Council (ALS, ILS, AIMS training) and

the resources available to support patients who become unwell are up to date

and readily available.

Under Caring we will focus on:

The introduction of ‘Intentional Rounding’ to our inpatient ward. Fitzsimmons, B.

et al (2011) Intentional rounding: its role in supporting essential care.

Nursing Times; 107: 27, 18-21.

The key aspects checked during intentional rounds will include the “Four P’s”

Positioning: Making sure the patient is comfortable and assessing the risk of

pressure ulcers

Personal needs: Scheduling patient trips to the bathroom to avoid risk of falls

Pain: Asking patients to describe their pain level on a scale of 0 - 10

Placement: Making sure the items a patient needs are within easy reach

During each round we will ensure the following behaviours are undertaken by the

Registered Nurse/HCA using an opening phrase to introduce themselves and put

the patient at ease perform scheduled tasks, ask about the “Four P’s” assess the

care environment (e.g. fall hazards, temperature of the room) use closing key

words e.g. ‘is there anything else I can do for you before I go?’ explain when the

patient will be checked on again document the round. We will develop a standard

for staff working on the inpatient ward describing the process and their role in

intentional rounding.


Under Responsive we will continue to focus on:

Improving our patient satisfaction response rates following the move to a new

customer satisfaction survey run by an external company assigned by Ramsay.

The new system allows for real time reporting and provides a net promoter score

for each hospital as well as a Ramsay average. The Senior Leadership Team will

monitor the dashboard weekly sharing feedback with the Heads of Department to

drive improvements where necessary and congratulate teams and individuals

where positive feedback is received.

Under Well Led we will focus on:

Developing a process where every patient’s discharge is seamless, where

patients are fully informed and are part of their discharge planning to enhance

patient safety and experience. We recognises that to facilitate a smooth

discharge from care in hospital the discharge plan must be well defined, prepared

and agreed with each individual patient and their family / carer. To allow sufficient

time for suitable and safe arrangements to be made, discharge planning should

begin at pre-admission clinics, with a predicted date of discharge. We will ensure

every patient is discharged from the ward when clinically ready and medically fit,

in a controlled, organised and safe manner. We will develop a standard for all

nurses and clinical practitioners who are involved in patient discharge to follow.


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 2018/19 Tees Valley Hospital provided and/or subcontracted 10 NHS

services.

The Tees Valley Hospital has reviewed all the data available to them on the

quality of care in all of these NHS services.

The income generated by the NHS services reviewed from 1 April 2018 to 31st

March 19 represents 100% of the total income generated from the provision of

NHS services by the Tees Valley Hospital for 1 April 2018 to 31st March 19.

Ramsay uses a balanced scorecard approach to give an overview of audit results

across the critical areas of patient care. The indicators on the Ramsay scorecard

are reviewed each year. The scorecard is reviewed each quarter by the hospitals

senior managers together with Regional and Corporate Senior Managers and

Directors. The balanced scorecard approach has been an extremely successful

tool in helping us benchmark against other hospitals and identifying key areas for

improvement.

In the period for 2018/19, the indicators on the scorecard which affect patient

safety and quality were:

Human Resource

Staff Cost % Net Revenue 34%

HCA Hours as % of Total Nursing 46%

Agency Cost as % of Total Staff Cost 16%

Admitted Care Hours Worked PPD 6.9

Staff Turnover 13.5%

Sickness 3.9%

Lost Time 17%

Appraisal % 89%

Mandatory Training % 87%

Staff Satisfaction Score 82% contracted staff responded to the survey

Number of Significant Staff Injuries No significant staff injuries were reported.

Patient

Formal Complaints in year 7


Patient Satisfaction Score 95%

Significant Clinical Events 3

Readmission in year 4

Quality

Workplace Health & Safety Score 92%

2.2.2 Participation in clinical audit

During 1st April 2018 to 31st March 2019, Tees Valley Hospital participated in two

national clinical audits.

The national clinical audits that Tees Valley Hospital participated in, and for which

data collection was completed during 1st April 2018 to 31st March 2019, are listed

below alongside the number of cases submitted to each audit or enquiry as a

percentage of the number of registered cases required by the terms of that audit

or enquiry.

Name of audit / Clinical Outcome Review Programme

% cases

submitted

National Joint Registry (NJR) 100%

Elective surgery (National PROMs Programme) 76%

The reports of the national clinical audits from 1 April 2018 to 31st March 2019

(schedule attached in appendix?) were also reviewed by the Clinical Governance

Committee.

2.2.3 Participation in Research

There were no patients recruited during 2018/19 to participate in research

approved by a research ethics committee.

2.2.4 Goals agreed with our Commissioners using the CQUIN

(Commissioning for Quality and Innovation) Framework

A proportion of Tees Valley Hospitals income in from 1 April 2018 to 31st March

2019 was conditional on achieving quality improvement and innovation goals

agreed Tees Valley Hospital and any person or body they entered into a contract,

agreement or arrangement with for the provision of NHS services, through the

Commissioning for Quality and Innovation payment framework.


2.2.5 Statements from the Care Quality Commission (CQC)

Tees Valley Hospital is required to register with the Care Quality Commission and

its current registration status on 31st March is registered without conditions. Tees

Valley Hospital has not participated in any special reviews or investigations by the

CQC during the reporting period. In order to open as a new hospital Tees Valley

Hospital was granted operational rights following a CQC building inspection.

2.2.6 Data Quality

Statement on relevance of Data Quality and your actions to improve your

Data Quality

Reliable information, and the quality of the underlying data that supports it, is fundamental to deliver effective treatment of patients.

Access to data that is accurate, valid, reliable, timely, relevant, complete, unambiguous and unique is crucial in supporting all levels of patient care, management processes, clinical governance, service agreements, remuneration, accountability and future healthcare planning. High quality data provide the tools to make healthcare safer and more effective.

Tees Valley Hospital will be taking the following actions to improve data quality.

Review processes to ensure the accuracy of any personal data we obtain

Routine audit and management of patient records

Feedback on CQUIN indicators and milestones

Ensure the data collected is fit for purpose with timely collection and monitoring.

NHS Number and General Medical Practice Code Validity

The Ramsay Group submitted records during 2018/19 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:

100% for admitted patient care;

100% for outpatient care; and

Accident and emergency care N/A (as not undertaken at Ramsay hospitals).

The General Medical Practice Code:

100% for admitted patient care;

99.9% for outpatient care; and


Accident and emergency care N/A (as not undertaken at Ramsay hospitals). Data Security & Protection Toolkit attainment levels (previously IG Toolkit) Ramsay Group DSP Assessment Report overall for 2018/9 was 83% and was graded as ‘Standards Met’. A score is no longer assigned.

This information is publicly available on the DSP website at:

https://www.dsptoolkit.nhs.uk/

Clinical coding error rate

Hospital Site Next Audit Date

Primary Diagnosis

Secondary Diagnosis

Primary Procedure

Secondary Procedure


June 2019 100% 100% 100% 100%

https://www.dsptoolkit.nhs.uk/


2.2.7 Stakeholders views on 2018/19 Quality Account


Part 3

Review of quality performance 2018/2019

Statements of quality delivery

Head of Clinical Services (Matron), Katie Lunn

Review of quality performance 1st April 2018 - 31st March 2019

Introduction

“This publication marks the ninth successive year since the first edition of

Ramsay Quality Accounts. Through each year, month on month, we analyse our

performance on many levels, we reflect on the valuable feedback we receive from

our patients about the outcomes of their treatment and also reflect on

professional assessments and opinions received from our doctors, our clinical

staff, regulators and commissioners. We listen where concerns or suggestions

have been raised and, in this account, we have set out our track record as well as

our plan for more improvements in the coming year. This is a discipline we

vigorously support, always driving this cycle of continuous improvement in our

hospitals and addressing public concern about standards in healthcare, be these

about our commitments to providing compassionate patient care, assurance

about patient privacy and dignity, hospital safety and good outcomes of

treatment. We believe in being open, transparent and honest where outcomes

and experience fail to meet patient expectation so we take action, learn, improve

and implement the change and deliver great care and optimum experience for our

patients.”

Vivienne Heckford

Director of Clinical Services


Ramsay Clinical Governance Framework 2019

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


National Guidance

Ramsay also complies with the recommendations contained in technology

appraisals issued by the National Institute for Health and Clinical Excellence

(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special

Health Authority.

Ramsay has systems in place for scrutinising all national clinical guidance and

selecting those that are applicable to our business and thereafter monitoring their

implementation.

3.1 The Core Quality Account indicators

The following tables and graphs show comparisons regarding key data between the following:

The best scoring hospital for this quality indicator based on all England hospitals providing NHS services

The worst scoring hospital for this quality indicator based on all England hospitals providing NHS services

The average score for this quality indicator

Tees Valley Hospital – there is no data from periods prior to the hospital opening in February 2018

Mortality

Prescribed Information Related NHS Outcomes Framework Domain

The data made available to the National 1: Preventing People from dying

Mortality: Period Period

Apr 16 - Mar 17 RKE 0.7075 RLQ 1.2123 Average 1 2017/18 NVC0R NA

Apr 17 - Mar 18 RJ1 0.6994 RE9 1.2321 Average 1 2018/19 NVC0R 0.0000

Best Worst Average Tees Valley

0

1

16/17 17/18 18/19

Unexpected Deaths



Health Service trust or NHS foundation trust by NHS Digital with regard to— (a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator.

prematurely 2: Enhancing quality of life for people with long-term conditions

The Tees Valley Hospital considers that this data is as described for the following reasons: there have been no patient deaths in the reporting period. Patient Reported Outcome Measures (PROMS)

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the trust’s patient reported outcome measures scores for— (i) groin hernia surgery, (ii) varicose vein surgery, (iii) hip replacement surgery, and (iv) knee replacement surgery, during the reporting period.

3: Helping people to recover from episodes of ill health or following injury

Tees Valley Hospital opened in February 2018 as a result there is no health gain data yet available for the PROMs for the periods reported. Readmissions – absolute numbers

The data made available to the National Health Service trust or NHS foundation trust by

3: Helping people to recover from episodes of ill health or

0

2

4

6

8

16/17 17/18 18/19

Readmissions



NHS Digital with regard to the percentage of patients aged— (i) 0 to 14; and (ii) 15 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.

following injury

The Tees Valley Hospital considers that this data is as described for the following reasons – we have a very low rate of readmissions due to the case mix we offer. Venous Thromboembolism (VTE) Assessment

Period Best Worst Average

Period Tees Valley

17/18 Q4 Several 100% NT490 0.0% Eng 95.2% 17/18

Q4 NVC0R 99.0%

18/19 Q3 Several 100% NVC0M 14.7% Eng 95.7% 18/19

Q3 NVC0R 96.0%

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

5: Treating and caring for people in a safe environment and protecting them from avoidable harm

The Tees Valley Hospital considers that this data is as described for the following reasons - has a very low incidence of VTE in comparison to the England average. C. Difficile Rate: per 100,000 bed days


Period Tees Valley

2016/17 Several 0 Q71 82.6 Eng 13.2 2017/18 NVC0R NA

2017/18 Several 0 Q71 91.0 Eng 13.7 2018/19 NVC0R 0.0

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.


The Tees Valley Hospital considers that this data is as described for the following reasons – no C Difficile for the period


Serious Untoward Incidents (SUIs): (Severity 1 Only)


Period Tees Valley

Apr17 - Sep17

Several 0 RJW 0.64 Eng 0.15 2017/18 NVC0R NA

Oct17 - Mar18

Several 0 RWD 0.55 Eng 0.15 2018/19 NVC0R 0.00

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death


The Tees Valley Hospital considers that this data is as described for the following reasons - there were no severity 1 incidents in the period. Friends and Family Test

Oct Best Worst Average

Period Tees Valley

Jan-19 Several 100% RJR 71.0% Eng 96.0% Jan-19 NVC0R 100.0%

Feb-19 Several 100% NVC12 70.0% Eng 96.0% Feb-19 NVC0R 100.0%

% recommended

Friends and Family Test - Question Number 12d – Staff – The data made available by National Health Service Trust or NHS Foundation Trust by NHS Digital ‘If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation' for each acute & acute specialist trust who took part in the staff survey.

4: Ensuring that people have a positive experience of care

The Tees Valley Hospital considers that this data is as described for the following reasons – patient’s recommendation rates are high.


3.2 Patient safety

We are a progressive hospital and focussed on stretching our performance every

year and in all performance respects, and certainly in regards to our track record

for patient safety.

Risks to patient safety come to light through a number of routes including routine

audit, complaints, litigation, adverse incident reporting and raising concerns but

more routinely from tracking trends in performance indicators.

Our focus on patient safety has resulted in a marked improvement in a number of

key indicators as illustrated in the graphs below.

3.2.1 Infection prevention and control

Tees Valley Hospital has a very low rate of hospital acquired infection and

has had no reported MRSA Bacteraemia since opening in February 2018.

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.


Rate per 100 discharges

Programmes and activities within our hospital include:

The Infection Control Link Nurse provides mandatory training in different areas of

infection control on an annual basis to all staff. We encourage all patients to

return to the hospital if they have any concerns regarding post-operative wound

infections rather than using their own GP.

Hand hygiene awareness days are led by the Infection Control Link Nurse

involving staff, patients and visitors and information in waiting areas.

Observational hand hygiene audits are also undertaken by the Infection Control

Link Nurse.

As can be seen in the above graph our infection control rate remains very low. As

the hospital did not open until February 2018 there is no data for the previous

years detailed.

3.2.2 Cleanliness and hospital hygiene

Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) Tees Valley Hospital took part in its first PLACE assessment providing us with a patient’s eye view of the buildings, facilities and food we offer, giving us a clear picture of how the people who use our hospital see it and how it can be improved. The main purpose of a PLACE assessment is to get the patient view. Results for 2018 were: Cleanliness 100% Food/hydration 90% Organisational food 88.18% Ward food 93.47%

0.00%

0.20%

0.40%

16/17 17/18 18/19

Hospital Acquired Infections



Privacy and dignity 66% Dementia 66.91% Disability 74.55% Appearance and maintenance 97%

Results were reviewed at the hospital infection control committee and an action

plan agreed for each area.

3.2.3 Safety in the workplace

Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to

incidents around sharps and needles. As a result, ensuring our staff have high

awareness of safety has been a foundation for our overall risk management

programme and this awareness then naturally extends to safeguarding patient

safety. Our record in workplace safety as illustrated by Accidents per 1000

Admissions demonstrates the results of safety training and local safety initiatives.

Effective and ongoing communication of key safety messages is important in

healthcare. Multiple updates relating to drugs and equipment are received every

month and these are sent in a timely way via an electronic system called the

Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and

new and revised policies are cascaded in this way to our General Manager which

ensures we keep up to date with all safety issues.

3.3 Clinical effectiveness

Tees Valley Hospital has a Clinical Governance Committee that meet regularly

through the year to monitor quality and effectiveness of care. Clinical incidents,

patient and staff feedback are systematically reviewed to determine any trend that

requires further analysis or investigation. More importantly, recommendations for

action and improvement are presented to hospital management and medical

advisory committees to ensure results are visible and tied into actions required by

the organisation as a whole.

3.3.1 Return to theatre

Ramsay is treating significantly higher numbers of patients every year as our

services grow. The majority of our patients undergo planned surgical procedures

and so monitoring numbers of patients that require a return to theatre for

supplementary treatment is an important measure. Every surgical intervention

carries a risk of complication so some incidence of returns to theatre is normal.

The value of the measurement is to detect trends that emerge in relation to a


specific operation or specific surgical team. Ramsay’s rate of return is very low

consistent with our track record of successful clinical outcomes.

Our return to theatre rate has been very low in the first year.

3.3.2 Learning from Deaths requirements for 2018/19

We have not had any patient deaths since the hospital opened in February 2018. To ensure learning from incidents including deaths across the whole Ramsay Group lessons learned are shared in the form of ‘outcomes with learning’ by the Director of Clinical Services. Following a death in 2017 and subsequent Regulation 28 at a Ramsay hospital lessons learned were shared and an action plan developed locally to ensure shared learning. This included a review of procedures performed against volumes, skills available, review of NEWS training and competence and introduction of a daily NEWS huddle to identify patients at risk or triggering scores. The huddle will confirm actions required with the clinical and medical team in terms of management of at risk patients.

0

0.02

0.04

0.06

0.08

2016/17 2017/18 2018/19

Ret

rnn

to

Th

eatr

e

(Per

cen

tage

of

Ad

mis

sio

sns)

Tees Valley

Return to Theatre Score

0

1

16/17 17/18 18/19

Unexpected Deaths



3.3.3 Staff Who Speak up new for 2018/19

In 2018, Ramsay UK launched ‘Speak Up for Safety’, leading the way as the first healthcare provider in the UK to implement an initiative of this type and scale. The programme, which is being delivered in partnership with the Cognitive Institute, reinforces Ramsay’s commitment to providing outstanding healthcare to our patients and safeguarding our staff against unsafe practice. The ‘Safety C.O.D.E.’ enables staff to break out of traditional models of healthcare hierarchy in the workplace, to challenge senior colleagues if they feel practice or behaviour is unsafe or inappropriate. This has already resulted in an environment of heightened team working, accountability and communication to produce high quality care centred on the best interests of the patient.

Ramsay UK has an exceptionally robust integrated governance approach to clinical care and safety, and continually measures performance and outcomes against internal and external benchmarks. However, following a CQC report in 2016 with an ‘inadequate’ rating, coupled with whistle-blower reports and internal provider reviews, evidence indicated that some staff may not be happy speaking up and identifying risk and potentially poor practice in colleagues. Ramsay reviewed this and it appeared there was a potential issue in healthcare globally, in response to this Ramsay introduced ‘Speaking Up for Safety’.

The Safety C.O.D.E. (which stands for Check, Option, Demand, Elevate) is a toolkit which consists of these four escalation steps for an employee to take if they feel something is unsafe. Sponsored by the Executive Board, the hospital Senior Leadership Team oversee the roll out and integration of the programme and training at Tees Valley Hospital and across Ramsay. The programme is employee led, with staff delivering the training to their colleagues, supporting the process for adoption of the Safety C.O.D.E through peer to peer communication. Training compliance for staff and consultants is monitored corporately; the company benchmark is 85%.

Since the programme was introduced serious incidents, transfers out and near

misses related to patient safety have fallen; and lessons learnt are discussed

more freely and shared across the organisation weekly. The programme is part of

an ongoing transformational process to be embedded into our workplace and

reinforces a culture of safety and transparency for our teams to operate within,

and our patients to feel confident in. The tools the Safety C.O.D.E. used, not only

provide a framework for process, but they open a space of psychological safety

where employees feel confident to speak up to more senior colleagues without

fear of retribution. Ramsay UK is currently embedding the second phase of the

programme which focuses on Promoting Professional Accountability, specifically


targeted for peer to peer engagement for our Consultant users who work at Tees

Valley Hospital and within Ramsay Health Care.

3.3.4 Priority Clinical Standards for Seven Day Hospital Services

“The provision of ‘Seven Day Services’ is a requirement of the NHS Standard

Contract and in essence requires providers of acute care to deliver high quality

care and improve outcomes on a seven day basis for patients admitted to hospital

in an emergency. There are ten separate Standards that providers must aim to

achieve, with four of those being designated as being priority areas.

Ramsay Health Care has very few emergency admissions due to the nature of

services provided to NHS patients (which is generally elective planned care in

nature, rather than being emergency). As such many of the requirements of the

Seven Day Services Programme are not applicable to Ramsay Health Care.

Nonetheless Ramsay has been working to comply with the Standards and in line

with national guidance a self-assessment process is being undertaken during

spring/summer 2019.”

3.4 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 feedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.

Patient experiences are 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 DH bodies occurs as required and according to Ramsay and DH policy.


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

Continuous patient satisfaction feedback via a web based invitation Friends and family questions asked on patient discharge ‘We value your opinion’ leaflet Verbal feedback to Ramsay staff - including Consultants and Senior 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

3.4.1 Patient Satisfaction Surveys

Every patient is asked their consent to receive an electronic survey following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services.

We continue to record high overall satisfaction rates above 95% however response rates remain low. The senior management team continue to work with Heads of Departments to look at ways to encourage patient participation.

Our Achievements:

Five star for Food Hygiene

4.5 Star on NHS choices

No Never Event

JAG accreditation

Low formal complaints


Appendix 1

Services covered by this quality account

Services Provided Peoples Needs Met for:

Treatment

of Disease,

Disorder

Or injury

Cosmetic Surgery,

Dermatology,

Gastroenterology, General

Surgery, Gynaecology, Oral

Surgery, Orthopaedics,

Urology, Plastic surgery ,

Podiatry

All adults 18 years and over.

Surgical

Procedures

Day and inpatient Surgery.

Cosmetic Surgery, General

Surgery, Gynaecology, Oral

Maxillo Facial Surgery,

Orthopaedic Surgery, Plastic

Surgery, Urology

All adults 18 years 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

Imaging services including X

ray, a Mobile MRI and CT

Unit and Ultrasound.

GI Endoscopy, Phlebotomy,

Urinary Screening and

Specimen collection,

Urology

All adults 18 years and over

Family

Planning

Services

Gynaecology patient

pathway, insertion and

removal

of inter uterine devices for

medical purposes

All adults 18 years and over as

clinically indicated


Appendix 2 – Clinical Audit Programme 2018/19. Findings from the baseline audits determine the

hospital local audit programme to be developed for the remainder of the year.




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 Hospital Director using

the contact details below.

For further information please contact:

Donna Thornton


Church Lane

Acklam

TS5 7DX

01642 087333

www.teesvalleyhospital.co.uk

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