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Quality Accounts 2010 /11

Quality Accounts 2010/11 of 56

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 Quality Priorities 10

2.1.1 Review of clinical priorities 2010/11 (looking back) 10

2.1.2 Clinical Priorities for 2011/12 (looking forward) 11

2.2 Mandatory statements relating to the quality of NHS services provided

16

2.2.1 Review of Services 16

2.2.2 Participation in Clinical Audit 19

2.2.3 Participation in Research 21

2.2.4 Goals agreed with Commissioners 22

2.2.5 Statement from the Care Quality Commission 22

2.2.6 Statement on Data Quality 22

2.2.7 Stakeholders views on 2010/11 Quality Accounts 25

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.0 Review of quality performance 26

3.1 Patient Safety 28

3.1.1 Infection prevention and control 28

3.1.2 Cleanliness and hospital hygiene 30

3.1.3 Safety in the workplace 30

3.2 Clinical Effectiveness 31

3.2.1 Return to theatre 31


3.2.2 Readmission to hospital 32

3.3 Patient Experience 33

3.3.1 Patient satisfaction surveys 34

3.3.2 Patient reported outcome measures (PROMS) 36

3.4 Case Study 38

Appendix 1 – Clinical Audits 40

Appendix 2 – CQUIN schedule 41


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)


Welcome to Clifton Park NHS Treatment Centre Clifton Park NHS Treatment Centre was purpose built and opened in January 2006 as part of the national GC4 contract to deliver elective NHS activity for a 5 year period. All GC4 patients were referred via North Yorkshire and York Primary Care Trust (85%) and East Riding of York Primary Care Trust (15%). In October 2010 the hospital secured a further 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 2010 to 31st March 2011 the hospital has treated 2896 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, 17 Health Care Assistants, 10 Allied Health Professionals and 39 support staff which includes porters, hotel services and 20 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. During 2010 we strengthened our links with GP groups by the Chairman of York Health Group becoming a member of our monthly Contract Management Board.


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.

The previous Quality Account for 2009/10 was developed by our Corporate Office

and summarised and reviewed quality activities across every hospital and centre

within the Ramsay Health Care UK. It was recognised that this didn’t provide enough

localised 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 will develop its own Quality Account

from this year onwards, which will include some Group wide initiatives, but will also

describe 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

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 first 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 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.


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


Part 2

2.1 Quality priorities for 2010/2011

Plan for 2010/11 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 2010/11

• Bar coding for patient identity bands – this priority did not progress last year, as the Department of Health’s Information Standards Board (ISB) advance notice was not followed up with a formal notice for implementation. Consequently the project was put on hold until further advice was received from the ISB. However, this is still on Ramsay’s agenda and will be introduced this year as it is still considered best practice and will prepare us for many patient care initiatives which will require patients to have a barcode on their wristbands. In preparation for this Clifton Park NHS Treatment Centre electronically prints all patient identity bands as per the NPSA ‘Standardising Wrist Bands Alert’ 2007

• Safer Surgery Checklists – further work was undertaken and the process is now fully embedded into our operational pathways and monitored through regular audit to further reduce the risk of wrong site surgery.

• Cleanliness – Further infection prevention and control audits were introduced as planned and these are now being undertaken at all Ramsay sites and action plans developed locally where necessary to ensure the standards are met. PEAT (Patient Environment Action Team) audits were also repeated and


showed an improvement of 3% to achieve 99% compliance, towards the end of this quality account period a programme of refurbishment was implemented.

• More time to care - Improve ward efficiency by adopting the Productive Ward initiative. The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for Innovation and Improvement (2008). It focuses on the way ward teams work together and organise themselves, in order to reduce the burden of unnecessary activities, and releasing more time to care for patients in a reliable and safe manner within existing resources. The approach is very much ‘bottom up’ with all ward staff suggesting ideas and ways in which they could improve their environment and processes. The Productive Ward project was successfully piloted at Clifton Park NHS Treatment Centre during 2010. The main areas of focus were: Effective use of resource and facilities; Medication rounds; Mealtimes and Communication. The staff embraced and implemented the changes they identified with commitment and enthusiasm to enable them to achieve the objective of releasing time for hands on clinical care, in turn improving the patient experience

2.1.2 Clinical Priorities for 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. At Clifton Park NHS Treatment Centre a project was undertaken during 2010 to monitor the number of patient and staff falls, identify the risks and formulate an action plan to minimize slips/trips and falls. 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

Year Patient Falls

Per 1000 admits

Staff falls

Per 1000 admits

2008/09 14 4.0 0 0 2009/10 6 1.7 1 0.3 2010/11 8 2.6 0 0

The improvement seen since 2008/09 is attributed to the introduction of a comprehensive action plan focusing on assessment and patient information to reduce the risk of falling. Focus will once again in 2011/12 be placed on patient fall reduction as the falls per 1000 admits shows an increase in 2010/11.

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 are undergoing 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 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/PublicationsStatistics/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

2009/10 Q4

2010/11 Q1

2010/11 Q2

2010/11 Q3

2010/11 Q4

Consent & linkability % 100 100 100 99 94 BMI Rate % 31 75 97 100 99

This information was able to be of assistance in the following Metal on Metal hip replacement recall. On 22nd April 2010 the Medicines and healthcare products Regulatory Agency (MHRA) issued a Medical Device Alert Ref MDA/2010/033 relating to all metal-on-metal (MoM) hip replacements. The MHRA had received reports of revisions of MoM replacements involving soft tissue reactions. Further guidance was issued by the MHRA on 7th September 2010 ref MDA/2010/069 relating specifically to DePuy ASR hip replacement implants. At Clifton Park since opening in 2006 347 ASR hip replacement operations had taken place. The aim at Clifton Park is to ensure 100% of patients who have received a DePuy ASR MoM hip replacement are followed up as per the guidance. The guidance in the above Medical Device Alerts has been commenced and update status is reported at the units Clinical Governance meetings to date 85% of patients have attended for follow up since this alert was issued. Further detail on the process and action can be found in section 3.4 CPTC case study.

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 = 95% Bunion surgery = 63.6% Dupuytrens = 96.5% Carpal Tunnel = 99.2% Overall = 71% The low % on bunion surgery is due to late surgery combined with another foot procedure; however this is being addressed as follows: 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. 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. 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” supported by a full training programme for relevant staff to be completed by end of June 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.


• 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: Hips 76.3%% (Nationally 79.6%) Knees 79.5%% (Nationally 81.9%) Clifton Park Treatment Centre was also a POIS pilot site and, until recently, ran the Oxford Hip and Knee Score Audit, through The Leadership Factor, collating five years of outcome data.

Written information about proposed treatment before admission

92.90% 90.80%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Q4 2010 Q1 2011


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 2010/11 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 2010 to 31 March 2011 represents 95% per cent of the total income generated from the provision of NHS services by Clifton Park NHS Treatment Centre from 1 April 2010 to 31 March 2011. 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 2010/11, 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 0.7%

• 7.9% Staff Turnover

• 2.97% Sickness

• Mandatory Training = 85% completed in last 12 months

• Number of Significant Staff Injuries = 0

• Appraisals = 85% completed in last 12 months

• Staff Satisfaction Score = 2009 92.1% and 2010 96.7% Ramsay undertakes an annual staff satisfaction survey known as the PULSE survey. Following this survey a local hospital team is formed and an action plan developed to improve staff satisfaction.


The graphs below show the increases in staff satisfaction from 2009 to 2010.

I enjoy my work 2010

I enjoy my work 2009


I have clear goals and objectives 2010

I have clear goals and objectives 2009

In addition to this survey in 2010, Clifton Park NHS Treatment Centre participated in the Healthcare 100 awards. The awards, researched by Ipsos MORI on behalf of HSJ and Nursing Times, and supported by the Department of Health and NHS Employers, is based on the results of an exclusive poll of the employees of registering organisations. Open to both NHS and independent healthcare providers in the acute, primary care, mental health and ambulance sectors, the winners and representatives of all those included in the top 100 list celebrated at a special Awards evening held at the London Hilton on Park Lane on Wednesday, July 7, 2010. Clifton Park NHS Treatment Centre was included in the top 100 list.


Patients 19 x Formal complaints 1st April 2010 to 31st March 2011 = 0.6% 93.7% Patient Satisfaction Score 0 significant reportable patients during 2010 = 0.0%. 9 Readmissions patients in 2010 = 3 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 86% compliance and an action plan has been developed to correct the key areas identified. A Disability Discrimination Act audit was carried out in March 2011. Our overall Infection Control Audit score is 98%.

2.2.2 Participation in Clinical Audit During 1 April 2010 to 31 March 2011, five national clinical audits and National Confidential Enquiries covered NHS services that Clifton Park NHS Treatment Centre provides. The national clinical audits and national confidential enquiries that Clifton Park NHS Treatment Centre was eligible to participate in during 1 April 2010 to 31March 2011 are as follows: - National Clinical Audits and National Confidential Enquiries (NA = not applicable to the services provided)

Name of Audit Participation (NA, Yes, No)

% cases submitted

Peri- and Neonatal NA NA Children Paediatric pneumonia (British Thoracic Society)

NA NA

Paediatric asthma (British Thoracic Society) NA NA Paediatric fever (College of Emergency Medicine) NA NA Childhood epilepsy (RCPH National Childhood Epilepsy Audit) NA NA Paediatric intensive care (PICANet) NA NA Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit)

NA NA

Diabetes (RCPH National Paediatric Diabetes Audit) NA NA

Acute care Emergency use of oxygen (British Thoracic Society)

NA NA

Adult community acquired pneumonia (British Thoracic Society)

NA NA

Non invasive ventilation (NIV) - adults (British Thoracic Society)

NA NA


Pleural procedures (British Thoracic Society) NA NA Cardiac arrest (National Cardiac Arrest Audit) YES O%

Vital signs in majors (College of Emergency Medicine) NA NA Adult critical care (Case Mix Programme) NA NA Potential donor audit (NHS Blood & Transplant) NA NA

Long term conditions Diabetes (National Adult Diabetes Audit)

NA NA

Heavy menstrual bleeding (RCOG National Audit of HMB) NA NA Chronic pain (National Pain Audit) NA NA Ulcerative colitis & Crohn’s disease (National IBD Audit) NA NA Parkinson’s disease (National Parkinson’s Audit) NA NA COPD (British Thoracic Society/European Audit) NA NA Adult asthma (British Thoracic Society) NA NA Bronchiectasis (British Thoracic Society) NA NA

Elective procedures Hip, knee and ankle replacements (National Joint Registry)

YES

100%

Elective surgery (National PROMs Programme) YES 100%

Cardiothoracic transplantation (NHSBT UK Transplant Registry)

NA NA

Liver transplantation (NHSBT UK Transplant Registry) NA NA Coronary angioplasty (NICOR Adult cardiac interventions audit)

NA NA

Peripheral vascular surgery (VSGBI Vascular Surgery Database)

NA NA

Carotid interventions (Carotid Intervention Audit) NA NA CABG and valvular surgery (Adult cardiac surgery audit) NA NA

Cardiovascular disease Familial hypercholesterolaemia (National Clinical Audit of Mgt of FH)

NA NA

Acute Myocardial Infarction & other ACS (MINAP) NA NA Heart failure (Heart Failure Audit) NA NA Pulmonary hypertension (Pulmonary Hypertension Audit) NA NA Acute stroke (SINAP) NA NA Stroke care (National Sentinel Stroke Audit) NA NA

Renal disease Renal replacement therapy (Renal Registry)

NA NA

Renal transplantation (NHSBT UK Transplant Registry) NA NA Patient transport (National Kidney Care Audit) NA NA Renal colic (College of Emergency Medicine) NA NA

Cancer Lung cancer (National Lung Cancer Audit)

NA NA

Bowel cancer (National Bowel Cancer Audit Programme) NA NA Head & neck cancer (DAHNO) NA NA

Trauma Hip fracture (National Hip Fracture Database)

NA NA

Severe trauma (Trauma Audit & Research Network) NA NA


Falls and non-hip fractures (National Falls & Bone Health Audit)

NA NA

Psychological conditions NA activity

Blood transfusion O neg blood use (National Comparative Audit of Blood Transfusion)

NA NA

Platelet use (National Comparative Audit of Blood Transfusion) NA NA

Additional Audits

National Surveillance Programme (HPA) YES 100%

PEAT YES N/A

The reports of five national clinical audits from 1 April 2010 to 31 March 2011 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 that fell below 90%

• Pharmacy Audit 87% compliance – fridge temperatures were not always reset, therefore further training was given and instructions placed on fridge doors (to re-audit May 2011).

• Peripheral Intravenous Cannula Care Bundle 88% compliance – Not all Anesthetists wear gloves for cannulating – discussed with head of Anesthetics at Clinical Governance and to re-audit to assess compliance.

• Prescribing 88% - Drug omissions not always recorded with a code and Clinical reasons for omission not always documented. Discussed with nursing team and for further audit in May 2011.

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 “Clinical Evaluation of Deep Dish Rotating Platform”. However no patients have been entered into the trial to date.


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 2010 to 31st March 2011 (1st October 2010 – 31st March 2011) 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 The Care Quality Commission has not taken enforcement action against Clifton Park NHS Treatment Centre during 2010/11. 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 Statement on relevance of Data Quality and your actions to improve your 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. 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 Feb 2010 Aug 2010 Feb 2011 Anaesthetic records 93% 99% 98% Audit results for medical records audit: . Audit April 2010 July 2010 Sept 2010 Feb 2011 Medical records audit 100% 99% 100% 99% Secondary Uses Service (SUS) submissions - Since the commencement of the Standard Acute Contract, Clifton Park’s SUS submissions have been improving month-on-month. Over the entire period of the SAC, submissions were running at 99.4%. However, for the last three months of the 2010/2011 financial year, Clifton Park’s submissions 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 2010/11 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: 99.9% for admitted patient care; 99.7% for outpatient care; and 0% for accident and emergency care (not undertaken at our hospital).


Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report overall score for 2010/11 was 79% and was graded ‘green’ (satisfactory). Clinical coding error rate Clifton Park NHS Treatment Centre was subject to the Payment by Results clinical coding audit during 2010/11 carried out by the Audit Commission. The following two paragraphs are quoted directly from the final Audit document, which explains the variance between what was audited and what was actually required of the Treatment Centre by the GC4 contract the hospital was working to. Relevant passages are highlighted.

1 Our audit is undertaken using the HRG4 grouper. Activity at Clifton

Park was under the GC4 contract until September 2010 which is

reported and billed under HRGv3.5. If we grouped this activity

using HRGv3.5 the HRG error rate would have been 3 per cent –

which would place the provider in the best performing 20 per

cent of Trusts using the 2009/10 audits.

2 However, for the purpose of this audit we group the financial

outcome of any errors in HRG 4. This is consistent across all

independent sector providers audited this year and makes no

reference to any locally or nationally agreed prices with the providers.

% Primary Diagnosis Incorrect

% Secondary Diagnosis Incorrect

% Primary Procedures Incorrect

% Secondary Procedures Incorrect

17 29.7 47 5.6

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. All areas for improvement identified as part of the audit are now completed. NHS North Yorkshire and York were present at the audit feedback and were supportive of our action plan.


2.2.7 Stakeholders views on 2010/11 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. CLIFTON PARK NHS TREATMENT CENTRE QUALITY ACCOUNT STATEMENT 2011 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 2010/11 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 the Clifton Park NHS Treatment Centre has provided assurance to us as Commissioners by sharing a breadth of data and quality metrics which have 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:-

• 93.7% 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.

• Excellent results for data quality for anaesthetic and medical records audit

• Clifton Park NHS Treatment Centre was included in the top 100 list for the Healthcare 100 awards.

• Strengthening links with GP groups – the Chair of York Health Group is a member of the Contract Management Board

The priorities detailed in the Quality Account for 2011/12 clearly identify the three elements of quality i.e. patient safety, clinical effectiveness and patient experience and have a real synergy with what we are seeking to achieve across the whole of NHS North Yorkshire and York. Clifton Park NHS Treatment Centre has identified the following priorities for 2011/12:-

• Bar coding for patient identify bands

• Safer Surgery Checklists

• Cleanliness – infection prevention and control audits

• More time to Care – adopting the Productive Ward initiative

• Falls – on admission a ‘risk of falls assessment’ is performed for every patient.

• 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.

• Patient Satisfaction Survey – improved patient information 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 trust, and we would like to congratulate them on their many quality achievements in 2010/11 and look forward to working collaboratively with the organisation in 2011/12.

Bill Redlin Director of Standards NHS North Yorkshire and York


Part 3

Statements of quality delivery

Matron, Gwenn Mather

3.0 Review of quality performance 1 April 2010 - 31 March 2011

Introduction

“Ramsay operates a quality framework to ensure the organisation is accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” (Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)

Ramsay Clinical Governance Framework 2011

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

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.


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 5 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.


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%.

Hospital Acquired Infections 2009

0

0.2

0.4

0.6

0.8

1

1.2

Nu

mb

er

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

Rate

HAI's Number 0 0 0 1 0 0 0 1 0 0 0 0

HAI's Rate 0.0% 0.0% 0.0% 0.4% 0.0% 0.0% 0.0% 0.5% 0.0% 0.0% 0.0% 0.0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Hospital Acquired Infections 2010

0

0.2

0.4

0.6

0.8

1

1.2

Nu

mb

er

0.0%

0.1%

0.1%

0.2%

0.2%

0.3%

0.3%

0.4%

0.4%

0.5%

Rate

HAI's Number 0 0 0 0 0 0 0 0 0 0 0 1

HAI's Rate 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4%



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.

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.

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

• 2009 = 8.6 per 1000 admits

• 2010 = 14.5 per 1000 admits

• 2011 = 12.5 per 1000 admits (to March 31st)

PEAT Audit results 2009 - 2011

95

96

99

93

94

95

96

97

98

99

100

2009 2010 2011


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.

Unplanned Returns to Theatre 2009

0

0.2

0.4

0.6

0.8

1

Nu

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er

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%R

ate

Unplanned Return to Theatre Number 0 0 0 0 0 0 0 0 0 0 0 0

Unplanned Return to Theatre Rate 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%



As can be seen in the above graphs our returns 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.

Unplanned Returns to Theatre 2010

0

0.2

0.4

0.6

0.8

1

1.2

Nu

mb

er

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

Ra

te

Unplanned Return to Theatre Number 0 1 0 0 0 0 0 1 0 0 0 0

Unplanned Return to Theatre Rate 0.0% 0.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.7% 0.0% 0.0% 0.0% 0.0%


Unplanned Re-admissions 2009

0

0.5

1

1.5

2

2.5

Nu

mb

er

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

Rate

Unplanned Re-admissions Number 1 2 1 1 1 0 0 2 1 1 0 0

Unplanned Re-admissions Rate 0.4% 0.9% 0.3% 0.4% 0.3% 0.0% 0.0% 1.0% 0.3% 0.4% 0.0% 0.0%



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 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: � 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.

Unplanned Re-admissions 2010

0

0.5

1

1.5

2

2.5

3

3.5

Nu

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er

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

Ra

te

Unplanned Re-admissions Number 2 3 0 0 1 1 1 0 0 0 0 0

Unplanned Re-admissions Rate 0.7% 1.0% 0.0% 0.0% 0.3% 0.3% 0.4% 0.0% 0.0% 0.0% 0.0% 0.0%



� 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%.

As can be seen in the above graph our Patient Satisfaction rate decreased from 95.6% in Q4 of 2010 Oct – Dec to 93.7% in Q1 of 2011 Jan - Mar. 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.

Patient Satisfaction Levels Q4 2011 v Q1 2011

95.60% 93.70%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Q4 2010 Q1 2011


Examples of areas for improvement:

Despite being previously identified as an area for improvement this result shows a decline. Action to be taken includes additional written information regarding possible side effects to be provided to all patients. An explanation of medication given is to be added to our discharge checklist.

Although the last results show a high score this has declined from the previous quarter. Action: Support Services Manager undertaking review with housekeeping team to identify possible reason for lower result.

Enough explanation of medicines given before discharge

95%90.60%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 2010 Q1 2011

Satisfaction with cleanliness

100% 96.90%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 2010 Q1 2011


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 2011. Hip replacement patients Participation, linkage and return rates Clifton Park NHS

Treatment Centre National

HES episodes 632 113,968 Pre-operative questionnaires 482 90,711 Participation rate 76.3% 79.6%

Linked questionnaires 331 65,629 Linkage rate 68.7% 72.3% Post-operative questionnaires sent 356 67,631 Issue rate 73.9% 74.6% Post-operative questionnaires returned 304 53,957 Response rate 85.4% 79.8%

Hip Replacement - Oxford Hip Score - Adjusted Health Gain

17

17.5

18

18.5

19

19.5

20

20.5

21

21.5

22

CLIFTON PARK NHS

TREATMENT CENTRE

National National


Knee Replacement Patients Participation, linkage and return rates Clifton Park NHS

Treatment Centre National

HES episodes 755 127,982 Pre-operative questionnaires 600 104,853

Participation rate 79.5% 81.9% Linked questionnaires 407 70,667 Linkage rate 67.8% 67.4% Post-operative questionnaires sent 457 77,304 Issue rate 77.8% 73.7% Post-operative questionnaires returned 390 61,999

Response rate 83.5% 79.2%

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

Knee Replacement - Oxford Knee Score - Adjusted Health Gain

0

2

4

6

8

10

12

14

16

18

20

CLIFTON PARK NHS TREATMENT

CENTRE

National National


3.4 Clifton Park NHS Treatment Centre

Case Study The Depuy ASR metal on metal hip replacement recall process Background On 22nd April 2010 the Medicines and Healthcare products Regulatory Agency (MHRA) issued a Medical Device Alert (Ref MDA/2010/033) relating to all metal-on-metal (MoM) hip replacements. The MHRA had received reports of revisions of MoM replacements involving soft tissue reactions, and that these reactions may be associated with unexplained hip pain. Following the guidance issued on 22nd April, Clifton Park ceased using the DePuy ASR implant and MoM hip replacement surgery was only undertaken where it was deemed clinically necessary by the Consultant. Further guidance was issued on 25th May 2010 (Ref MDA/2010/044) regarding DePuy ASR acetabular cups used in hip resurfacing arthroplasty and total hip replacement. The problem was identified as having received higher than anticipated rates of revision for ASR acetabular cups. These initial alerts stated that the action which needed to be taken was to put systems in place for follow up of patients implanted with MoM hip replacements including, where appropriate, blood metal ion measurements and cross sectional imaging.

Initial Actions • Following this guidance Clifton Park stopped using the DePuy ASR implant and

MoM hip replacement surgery was only undertaken where it was deemed clinically necessary by the Consultant.

• The National Joint Registry (NJR), where details of all hip replacement surgery and prosthesis used are recorded, was contacted.

• The NJR were able to provide a spreadsheet detailing all MoM implants that had been used since Clifton Park opened in January 2006.

• These patients were then sent individual letters providing information regarding the medical device alert produced by DePuy (prosthesis manufacturer) and also information produced by the British Hip Society.

• A follow up was not routinely booked unless the patient had not attended follow up in the previous 12 months. However, the patients were asked to contact the Treatment Centre directly if they had any concerns.


Further guidance was issued by the MHRA on 7th September 2010 (Ref MDA/2010/ 069) relating specifically to DePuy ASR hip replacement implants. The action required was: not to implant the DePuy ASR hip replacements; return all used implants to the manufacturer; inform all patients with the implanted ASR hip about this recall and schedule a follow up visit.

Further actions Following this alert Clifton Park then contacted all patients who had not been in for review since the previous MHRA notice and booked a follow up appointment. All patients who attended their follow up were booked a Consultant appointment and x-rays, cobalt and chromium ion blood tests were undertaken.

• If the patients’ blood tests were raised, but they had no symptoms, then an appointment was made to repeat these tests in 3 months’ time.

• If the patients’ blood tests were raised, and they were symptomatic, then further investigations were ordered i.e. MRI and/or ultrasound.

• If blood levels and x-rays were asymptomatic, then further follow up was booked for 1 year.

The majority of patients who received the DePuy ASR implant at Clifton Park were funded by the NHS. The funding for these additional follow up appointments, pathology and imaging is claimed from DePuy via their appointed solicitors Broadspire.

Update At Clifton Park, since opening in 2006, 347 ASR hip replacement operations had taken place. The aim at Clifton Park is to ensure 100% of patients who have received a DePuy ASR MoM hip replacement are followed up as per the MHRA guidance. The guidance in the above Medical Device Alerts has been implemented and update status is reported at the unit’s Clinical Governance meetings. To date 85% of patients have attended for follow up since this alert was issued.


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


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

Indicator weighting

1 Reduce avoidable death, disability and chronic ill health from Venous-thromboembolism (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

Effectiveness

3 Hip and knee replacement best practice bundle

Regional

4

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

Patient Experience

Effectiveness

4 Care and Compassion – Nutritional screening

Regional

5

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

Patient Safety

Patient Experience

Effectiveness

5 Care and Compassion – Improvement of Pressure Ulcers

Regional


Goals and Indicators Local

Goal no.

Description of goal

Quality Domain(s)

Indicator number

Indicator name National or Regional indicator

Indicator weighting

6 Protection from infection

Patient Safety

Patient Experience


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

Local

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

Patient Safety

Patient Experience


7 Improve the identification of deterioration in condition

Improve the response to identified deterioration in condition

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

Local

8 Secure safe, high quality, co-ordinated care focused on hospital discharge arrangements

Patient Safety

Patient Experience


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

Local


Detail of Indicator (to be completed for each indicator)

Indicator 1 – VTE risk assessment

Description of indicator % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the national tool

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)

Rationale for inclusion

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.

Data source and frequency of collection

Monthly return through Unify

Organisation responsible for data collection

Provider

Frequency of reporting to Commissioner

Monthly

Baseline period / date Quarter 1

Baseline value

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

Quarter 4

Final indicator value (payment threshold)

90% achievement required

0.15% of National 0.3%

Final indicator reporting date Quarter 4

Indicator 2 – Composite indicator on responsiveness to personal needs


Description of indicator

The indicator will be a composite, calculated from 5 survey 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 • 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.


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

Frequency of reporting to Commissioner

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


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


To be agreed

Final indicator reporting date To be confirmed

Detail of Indicator 3 – Hip and Knee

Description of indicator Hip and knee replacement best practice bundle


Denominator 1 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 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


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


Provider Quarterly returns


Provider

Frequency of reporting to commissioner

At end of each quarter

Baseline period / date 2009/10 outturn

Baseline value



Quarter 4


0.042 of the Regional 0.5%


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 how the following indicators will be met to best practice standards in “Essence of Care”pp51-64 DH June 2009


1. Screening and assessment

People who are screened on initial contact and identified at risk receive a full nutritional assessment

2. Planning, implementation, evaluation and revision of care

People's care is planned, implemented, continuously evaluated and revised to meet individual needs and preferences for food and drink

3. Monitoring People's food and drink intake is monitored and recorded

4. Environment People feel the environment is conducive to eating and drinking

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

7. Provision People are provided with food and drink that meets their individual needs and preferences

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 health

People are encouraged to eat

Rationale for inclusion 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.


Provider quarterly


Provider


Quarter 1 - submit data (baseline)

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 value Action plan must be approved by commissioner and progress reported quarterly


Quarter 4







Submission of Action plan


Providers must agree their evidence based tool with their PCT commissioner accordingly.

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

Numerator 8 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

Rationale for inclusion Improve pressure ulcer prevention and management.


Quarterly


Provider


Quarterly


Baseline value Action plan must be approved by commissioner and progress reported quarterly


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




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.

(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


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.

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 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.

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



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


To be confirmed


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)

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 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

Numerator

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:

• Number of cardiac arrest calls per month

• Number of rapid response calls per month

• Number of patients who triggered that received an appropriate response

Denominator

Agreed sample of wards

Agreed sample of adults inpatients

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;

• 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


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


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



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


To be agreed


To be agreed


N/A


Final indicator reporting date 10 days after March 2011

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

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

Numerator

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?’

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


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

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


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


September 2011


Rules for partial achievement of indicator at year-end To be agreed


N/A


Final indicator reporting date 10 days after September 2011


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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