Boston West Hospital Quality Account 2013/14 Quality Accounts 2013/14 Page 1 of 52 Contents Introduction Page Welcome to Ramsay Health Care UK 3 Introduction to our Quality Account 4 PART 1 – STATEMENT ON QUALITY 5 1.1 Statement from the General Manager 5 1.2 Hospital accountability statement 7 PART 2 15 2.1 Priorities for Improvement 15 2.1.1 Review of clinical priorities 2013/14 (looking back) 15 2.1.2 Clinical Priorities for 2014/15 (looking forward) 16 2.2 Mandatory statements regarding quality of NHS services 20 2.2.1 Review of Services 20 2.2.2 Participation in Clinical Audit 23 2.2.3 Participation in Research 25 2.2.4 Goals agreed with Commissioners 25 2.2.5 Statement from the Care Quality Commission 27 2.2.6 Statement on Data Quality 27 2.2.7 Stakeholders views on 2013/14 Quality Accounts 29 PART 3 – REVIEW OF QUALITY PERFORMANCE 34 3.1 The Core Quality Account indicators 36 3.2 Patient Safety 40 3.3 Clinical Effectiveness 44 3.3 Patient Experience 45 3.4 Case Study 47 Appendix 1 – Services Covered by this Quality Account 49 Appendix 2 – Clinical Audits 50 Appendix 3 – Glossary 51 Quality Accounts 2013/14 Page 2 of 52 Welcome to Ramsay Health Care UK Boston West 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 Group. “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) Quality Accounts 2013/14 Page 3 of 52 Introduction to our Quality Account This Quality Account is Boston West 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. Quality Accounts 2013/14 Page 4 of 52 Part 1 1.1 Statement on quality from the General Manager Carl Cottam General Manager Boston West Hospital As the General Manager of Boston West Hospital I am passionate about ensuring that we deliver consistently high standards of care to all of our patients. Our Vision is that: “As a committed team of professional individuals we aim to consistently deliver quality holistic care for all of our patients across a full range of care services. We believe we are able to achieve this by continually updating our key skills and knowledge enabling us to deliver evidence based clinical practice throughout the Hospital. Boston West Hospital is a recognised Centre of Excellence for the delivery of day case services”. Our Quality Account details the actions that we have taken over the past year to ensure that our high standards in delivering patient care remain our focus for everything we do. Through our vigorous audit regime, and by listening to all our stakeholders, including patient feedback, we have been able to identify areas of good practice and where we can improve the care our patients receive. This has Quality Accounts 2013/14 Page 5 of 52 enabled us to refine some of our processes which have resulted in making further improvements. To ensure that we deliver clinical excellence depends on the whole team. We have an excellent training and education plan which involves all members of our administrative and clinical teams. Every individual member of staff is crucial to the success of our hospital and we value the contribution that they make in delivering great customer care. Our Quality Account has been produced to provide information about how we monitor and evaluate the quality of the services that we deliver. We hope to be able to share with the reader our progressive achievements that have taken place over the past 2-3 years. Boston West Hospital has a very strong track record as a safe and responsible provider of health care services and we are proud to share our results. Our Quality Accounts have been developed with the involvement of our staff who have been instrumental in developing a systems approach to risk management, which focuses on making every effort to reduce the likelihood and consequence of an adverse event or outcome associated with treatment of a patient. To ensure a coordinated approach to the delivery of care for patients and to monitor the adherence to professional standards and legislative requirements the Clinical Governance Committee and Medical Advisory Committee meet on a quarterly basis to review the clinical and safety performance of the Hospital. These committees have reviewed and agree with the content and action details within these Quality Accounts. As the General Manager I am aware of all aspects of clinical quality and NHS services provided at Boston West Hospital and can confirm the accuracy of this document. If you would like to comment or provide me with feedback then please do contact me on [email protected] or telephone: 01733 842329. Quality Accounts 2013/14 Page 6 of 52 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. Carl Cottam General Manager Boston West Hospital Ramsay Health Care UK This report has been reviewed and approved by: Medical Advisory Committee Chair: Mr. V. Csok Clinical Governance Committee Chair: Mr. M. Necas Regional Director, Midlands Region, Ramsay Health Care: Mr. James Beech The Patient & Public Involvement Forum Committee Members South Lincolnshire Clinical Commissioning Group Lincolnshire Health Watch Lincolnshire Health Overview and Scrutiny Committee Quality Accounts 2013/14 Page 7 of 52 Welcome to Boston West Hospital Boston West Hospital is a purpose built facility which provides services for assessment, diagnosis and treatment of common medical conditions, and has a suite of outpatient and treatment rooms which has recently been refurbished to create an additional spacious consultation room. A well-equipped modern theatre undertakes a range of surgical procedures and endoscopic (diagnostic) investigations. Support services include a three stage Sterile Services Unit, which meets the stringent standards set by the Department of Health. The Hospital provides NHS and private day case facilities for the following specialties: Orthopaedic Ophthalmology General Surgery Pain Management Gynaecology Gastroenterology Urology Physiotherapy Cosmetic Surgery Our full list of services can be found in Appendix 1. Quality Accounts 2013/14 Page 8 of 52 We provide safe, convenient, effective and high quality treatment for adult patients (excluding children below the age of 18 years), whether privately insured, self-pay, or from the NHS. A high percentage of our patients have come from the NHS sector, patients choosing to use our facility through ‘Choose and Book’. Our services help to ease the pressure on The Pilgrim NHS Hospital and Lincoln County Hospital and other local NHS facilities. We have worked closely with the Hospital Management Team and our NHS Clinical Commissioners, Lincolnshire South CCG, to ensure improved access for patients requiring day case surgery.