Winfield Hospital
Quality Account
2013/14
Contents
Introduction PageWelcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1 / Statement from the General Manager
1.2 / Hospital accountability statement
PART 2
2.1 / Priorities for Improvement
2.1.1 / Review of clinical priorities 2013/14 (looking back)
2.1.2 / Clinical Priorities for 2014/15 (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 2010/11 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
3.5 / Patient Feedback
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Winfield 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.
“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 Winfield 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 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 General Manager
Welcome to Winfield Hospital’s quality account, which I hope you will find both interesting and informative. This report outlines the Hospital’s approach to quality improvement, progress made in 2013 - 2014 and plans for the forthcoming year.
Winfield Hospital has five key values which underpin everything we do as an organisation. They are:
• Put the patient first;
• Work as one team;
• Respect each other;
• Strive for continual improvement;
• Respect environmental sustainability.
The experience that patients have in our hospital is of the utmost importance to us. As well as being treated safely and quickly, they must receive a personalised service, enhanced by good communication and a commitment to ensuring their privacy and dignity are respected at all times.
During 2013-2014 we have made a number of improvements to ensure that patients in our hospital receive the best possible care.
This report demonstrates that the experience patients have in our hospital, the quality of the care they receive, and the safety of the service we provide are top priorities for Winfield Hospital.
In addition, it shows how our values, combined with our priorities, are improving the way in which we treat our patients.
Richard Foulkes,
General Manager Winfield 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.
Richard Foulkes
General Manager
Winfield Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Dr Marion Andrews Evans, Director of Nursing and Quality, Gloucestershire Clinical Commissioning Group
Mr Rick Majkowski, consultant orthopaedic surgeon – Medical Advisory Committee Chair
Dr Richard Vanner, consultant anaesthetist - Clinical Governance Committee Chair
Mr Mike Scott, consultant colo-rectal surgeon, Clinical Governance Committee Chair and lead consultant for Endoscopy
Stefan Andrejczuk - Regional Director South
Mrs Mandy Keedwell – patient representative
Mr John Roberts – patient representative
‘Thank you for asking me to scrutineer the Quality account for 2013/14.the only point I would make is that some of the clinical abbreviations may not be clear to the layman, a glossary of these may help. It is very good to see improvements year on year. To achieve 100 percent is hard enough but to maintain it is harder. In conclusion I congratulate you and all the staff for achieving the high standards at all times. Many thanks for a very good report’
Unfortunately Healthwatch Gloucestershire was unable to make comment on this document this year.
Welcome to Winfield Hospital
Winfield Hospital is an independent hospital located on the outskirts of the city of Gloucester. It is situated off the Northern Ring Road with excellent road and rail links.
Consideration for our patients is at the heart of everything that we do. We are constantly seeking new ways of working and bringing in fresh clinical practices that will improve outcomes for our patients.
Our approach to service delivery, which currently includes working in partnership with the NHS, is courteous and professional and we take great pride in our ability to innovate and look at new ways of working.
Winfield Hospital has three theatres all with ultra clean air technology and a dedicated endoscopy suite The ward has 39 inpatient beds, 33 of which are single rooms and 3 doubles, all with en suite facilities. Two of the ward single rooms are designated High Dependency Beds offering level 2 critical care.
Diagnostic facilities include an imaging department with on site x-ray, ultrasound,and dental x-ray equipment. MRI andCT scanning services are supplied by Ramsay UK Diagnostic mobile units
We have a substantial physiotherapy department which has a fully equipped gymnasium and treatment rooms. Services include Hydrotherapy, Hand Therapy, Continence /Women’s Health, Sports Injuries, musculoskeletal assessment and treatment and Post Operative Rehabilitation, Pilates, Back School, Acupuncture, Phototherapy (UVB for skin conditions),and neurological rehab(strokes/MS/Parkinson’s)
The Hospital also has a well equipped outpatient department with 11 consulting rooms and a dedicated minor procedures area.
An onsite pharmacy registered with the Royal Pharmaceutical Society of Great Britain is also based within the department.
Delivering a full range of specialist surgical and medical services that include Cardiology, Dermatology, Endoscopy, ENT, General Surgery, Gynaecology, Plastic Surgery, Ophthalmology, Orthopaedics and Urology, we provide fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of 18 years for NHS care or 16 years if private).
Our pathology services are provided by Gloucestershire Royal Hospitals NHS Trust with whom we have a close working relationship for this plus other specialised clinical services that we are unable to provide in house.
At the Winfield Hospital we work closely with our local Clinical Commissioning Group to provide a range of surgical services under the “Any Qualified Provider” contract. We also have an excellent relationship with Tetbury Hospital and support their in-patient choice activity. We employ a GP liaison officer who has direct involvement with all the local GPs and who actively promotes Winfield as a Hospital of Choice.
We are committed to delivering services within the community where possible and actively seek opportunities to provide outreach clinics in rural areas.
In 2013 we treated a total of 5,250 patients. Of these 2,411 were private patients (46%) and 2839 were NHS patients (54%).
Winfield Hospital has 158 consultants with practising privileges and employs 180 staff, both clinical and non clinical.
The nursing staff to patient ratio on the ward ranges between 1:5 to1:8. This is calculated taking into account patient dependency but not in isolation. There is an experienced Residential Medical Officer (RMO) on site 24 hours a day
We offer direct referral services for private Cosmetic Surgery and aesthetic cosmetic treatments.
All patients requiring NHS services are referred via their General Practitioner (GP)
We regularly hold patient information evenings on different medical subjects and have recently held sessions on knee pain and snoring.
As part of the local community, staff at the Winfield Hospital regularly take part in events in Gloucestershire. A team of staff have taken part in the Race for Life three years running now and for the second year a team took part at the annual Dragon Boat Race at Gloucester Docks. Each year staff vote for a local charity for which to fundraise. This year Sue Ryder was nominated and money has been raised by staff quiz nights and raffles at the annual barbeque.
The rotary club in Gloucester utilise our car park on Gloucester Rugby Club match days to raise funds for themselves by charging a small parking fee. This is very popular with the fans!
Our meeting room is used frequently by local GP practices and medical charities and the Winfield Hospital is proud to support the local education trust for GP’s (GGPET) as a venue for their educational workshops and seminars.
Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Winfield 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 2013/14 (looking back)
Safer Surgery Checklists
The World Health Organisation (WHO) Surgical Safety Checklist is designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential care interventions.
At the Winfield Hospital we continually monitor our compliance with the WHO safer surgery checklists within our theatres. We undertake numerous internal audits of compliance and these now include pre and post theatre list briefings with the whole team to ensure a more robust approach.
Any audit scores that have been below the expected 100% during the year were reviewed by a clinical team within the hospital and lessons learnt fed back to the relevant staff.
VTE risk assessment
Our aim for 2013 / 14 was to ensure that 100% of all eligible patients admitted to the Winfield Hospital had a VTE risk assessment prior to surgery. We have achieved this and continue to assess all admitted patients.
RISKMAN
Ramsay Health Care UK is very diligent about how we manage risk in our hospitals, treatment centres and workplaces to ensure that safety is paramount for patients, staff and visitors. Ramsay Health Care UK are constantly looking at ways that risk and reporting incidents can be managed in an easier and more effective way. As such they implemented a risk reporting tool already in use in Australia in the UK.
RISKMAN became our reporting tool for compliments and complaints also last year and has developed further in 2013 – 14 as a risk register for the hospital and more recently the implementation of legal reporting through the same medium. This enables all patient and safety issues to be linked within the same system.
Meeting endoscopy standards
In February 2014 we achieved JAG accreditation for our endoscopy services. This is a prestigious achievement and Winfield Hospital is one of only two hospitals in Gloucestershire to have been awarded this.