Cobalt Hospital
Quality Account
2013/14
Quality Accounts 2013/14
Page 33 of 33
Contents
Welcome to Ramsay Health Care UK / 4Introduction to our Quality Account / 5
PART 1 – STATEMENT ON QUALITY / 6
1.1 / Statement from the General Manager / 6
1.2 / Hospital Accountability Statement / 7
1.2.1 / Cobalt Hospital / 8
PART 2 / 9
2.1 / Priorities for Improvement / 9
2.1.1 / Review of Clinical Priorities 2013/14 (looking back) / 9
2.1.2 / Clinical Priorities for 2014/15 (looking forward) / 11
2.2 / Mandatory statements relating to the quality of NHS services provided / 13
2.2.1 / Review of Services / 13
2.2.2 / Participation in Clinical Audit / 14
2.2.3 / Participation in Research / 15
2.2.4 / Goals agreed with Commissioners / 15
2.2.5 / Statement from the Care Quality Commission / 15
2.2.6 / Statement on Data Quality / 15
2.2.7 / Stakeholders views on 2013/14 Quality Accounts / 17
PART 3 – REVIEW OF QUALITY PERFORMANCE / 18
3.1 / The Core Quality Account indicators / 20
3.2 / Patient Safety / 23
3.3 / Clinical Effectiveness / 26
3.4 / Patient Experience / 27
3.5 / Case Study / 29
Appendix 1 – Services Covered by this Quality Account / 30
Appendix 2 – Clinical Audits / 31
Welcome to Ramsay Health Care UK
Cobalt Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group, was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs and Clinical Commissioning Groups.
“As Chief Executive of Ramsay Health Care UK, I am passionate about ensuring that high quality patient care is our number one goal. This relies not only on excellent medical and clinical leadership in our hospitals but also upon an organisation wide commitment to drive year on year improvement in patient satisfaction and clinical outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is not about reliance on one person or a small group of people to be responsible and accountable for our performance. It is essential that we establish an organisational culture that puts the patient at the centre of everything we do and as a long standing and major provider of healthcare services across the world, Ramsay has a very strong track record as a safe and responsible healthcare provider and we are proud to share our results.
Across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends. We value our people and with every year we set our targets higher, working on every aspect of our service to bring a continuing stream of improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Introduction to our Quality Account
This Quality Account is Cobalt Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient’s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this did not provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.
Part 1
1.1 Statement from the General Manager
“Cobalt Hospital is committed to being a leading provider of outpatient, diagnostic and day case services by delivering high quality outcomes and an excellent patient experience.”
I am delighted to introduce our Quality Account for 2013/14 which demonstrates our commitment to delivering high quality care. The report focuses upon our performance over the last year and describes our priorities for 2014/15.
Our approach to quality ishaving in place a robust framework which enables us to monitor and measure outcomes and experience, using this information to drive further improvement in patient safety, patient experience and clinical outcomes. Our team is at the forefront of delivering a quality service. “People caring for people” remains our philosophy and we are committed to training and developing our workforce and ensuring attitudes and behaviour aligned to our values.
This has been a busy and successful year with a wider number of GPs referring to our services and an increased number of patients choosing to access our hospital. Our missionremains, to beexpert in delivering elective day case services topatients in our local community and beyond, delivering services we would be happy to receive ourselves. We have had our commitment to quality recognised this year in a number of key achievements:
Ø The number of patients who have taken time to enter reviews on NHS choices and it is particularly pleasing to see that the hospital has an overall 5 star rating
Ø In addition, all of our patient feedback mechanisms show consistently high satisfaction
Ø We meet all CQC standards, an unannounced inspection took place in November and resulted in a very positive report with no conditions
Ø Only 2 complaints received in the last 12 months
Ø Obtaining Joint Advisory Group (JAG) accreditation for endoscopy services
Despite these accolades we are not complacent and our priorities for 2014/15 are focused upon ensuring continuous improvement, creating services centred around the patient,getting it right first time and putting patient safety at the heart of everything we do.
Donna Thornton
General Manager, Cobalt Hospital
1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.
Donna Thornton, General Manager
Cobalt Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Peter Hodgkinson, Medical Advisory Group Chair:
Alex Clason, Clinical Governance Committee Chair:
Stefan Andrejczuk, Regional Director:
Who comment that it is gratifying to confirm the high level of service provided by Cobalt Hospital which remains a front runner in the delivery of care in Ramsay Healthcare UK with its continued commitment to improvement and quality of patient care.
1.2.1 Cobalt Hospital
Cobalt Hospital, formerly Cobalt Treatment Centre, was built in 2005 and is a modern, purpose-built unit designed for the diagnosis, assessment and treatment of conditions on a day case basis for adults aged 18 years and over. The Hospital is a single level building comprising of a modern and airy reception area, an outpatient unit with a suite of consulting rooms and a surgical unit housing two theatres and dedicated recovery areas. Located within the Cobalt Business Park there is ample free car parking, good public transport links and easy access to main road networks.
Cobalt Hospital currently provides NHS services for the following specialties: GI endoscopy, general surgery, orthopaedics and plastic surgery. Patients who self pay or have private medical insurance are seen under our Premium Care scheme for the following specialties: cosmetic surgery, GI endoscopy, general surgery, orthopaedics and plastic surgery.
North of Tyne Clinical Commissioning Group were our lead commissioner of NHS Services for 2013/14, on behalf of neighbouring clinical commissioning groups, with regular service review meetings held to discuss performance. Patients were referred and travelled from Northumberland, North Tyneside, Newcastle, Sunderland, South Tyneside and Gateshead.
Referral to the hospital for NHS services is direct from GP via Choose and Book and we have dedicated Choose and Book Co-ordinators and a GP Liaison team to facilitate the referral process. We hold regular Choose and Book workshops at the hospital inviting medical secretaries from local GP practices. These events give an opportunity to tour the facilities and experience the ‘patient pathway’ first hand.
This year saw over 4,500 patient procedures at Cobalt Hospital with a breakdown of work being 97% NHS patients and 3% private patients. In terms of workforce there are 36 members of staff employed at Cobalt Hospital, a mix of full time and part time, of which 51% are clinical posts and 49% support staff.
Part 2
2.1 Priorities for Improvement 2013/2014
On an annual cycle, Cobalt Hospital develops an operational plan to set objectives for the year ahead.
We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.
2.1.1 A review of clinical priorities for 2014/15 (looking back)
Surgical safety checklist - There have been no ‘Never Events’ at Cobalt Hospital in the period and audit of compliance maintains a key focus with monthly audit of WHO safety checklists as part of CQUIN indicators undertaken by the Ambulatory Care Team Leader. Scores have ranged from 92% to 100% compliance and action plans are devised where there is evidence of noncompliance. The key area that causes noncompliance is at the sign out stage which will remain a focus in 2014.
VTE assessment – There has been improvement in compliance with completion of VTE documentation for patients where appropriate. Support from the Group Medical Director included a presentation to the Medical Advisory Committee on clinician responsibilities in the completion of VTE risk assessments. Quarterly audit scores have demonstrated improvement and compliance remain a focus across the whole of the Ramsay Group.
Infection Control – We have had no reportable infections and no outbreaks reported in the period. We continue to screen patients for MRSA where appropriate in line with DOH guidelines and training for staff on hand hygiene is mandatory. The infection control team have worked to improve standards in environmental cleaning in the period with the Clinical Lead leading quarterly environmental audits in the period. Improvements in completion of clinical equipment cleaning schedules have been noted following review of cleaning matrix and clarity of responsibilities. Low scores were in relation to none completion of cleaning schedules. Audit scores have improved from 84% in February 2013 to 92% in February 2014 and a CQUIN target has been set this year to further improve compliance.
PLACE (Patient lead assessment of the care environment) – The first PLACE assessment was carried out in June 2013, two patient representatives performed the assessment with two members of Cobalt Hospital staff including the General Manager and the Infection Control Link Nurse. The patients were both very impressed with the facilities and gave very positive feedback on the day.
Incident reporting – The Ramsay Group risk management system Riskman is used to report clinical incidents, health and safety incidents, compliments and complaints. Additional training has been given to all staff to ensure timely and effective reporting and compliance in reporting has been good. There have been no serious untoward incidents reported in the period.
Competency training – Competency assessment tools have been completed for all staff clinical staff appropriate to their area of practice.
Preoperative assessment – The preoperative assessment policy is followed and provides safe and efficient assessment of all patients following their outpatient clinic appointment. Patients complete a medical questionnaire which is reviewed by the nursing staff to determine the level of preoperative assessment required. We have modelled the patient pathway to include early patient assessment expanding boundaries and demonstrating excellence in practice. Our low conversion to inpatient demonstrated by our transfer rate of 1 per 1000 admissions is testament to good patient assessment and planning, setting patient expectation, anaesthetic techniques and staff expertise.
Meeting Endoscopy Standards – Cobalt Hospital was successful in achieving JAG accreditation in September 2013 following a comprehensive assessment. This is a huge achievement for the hospital endorsing the excellent endoscopy service provided to the local community.
Patient satisfaction survey – The web based satisfaction survey has been in place since February 2013 and response rates have gradually increased over the period with a response rate of 53.8% at the end of March 2104. The overall satisfaction rate for the year was 97%. We have gained a five staff rating on NHS choices following very positive patient feedback posts describing positive patient experience. We are proud to report that we received only two formal complaints in the period which is a huge achievement and a result we are extremely proud of. We introduced a patient focus group at the end of 2013 involving our staff in reviewing the many forms of patient feedback we receive and encouraging autonomy in making recommendations for practice.