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BMI Bishops Wood Hospital Quality Accounts
April 2013 to March 2014
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Chief Executive’s Statement
Welcome to our Quality Accounts 2014, the fifth year we have published this data. The
information presented here on a broad range of quality measures continues to grow in
importance and usefulness for patients and commissioners. Quality accounts already provide a
key metric for people to assess the strength of our 66 hospitals and
clinics against other facilities - NHS and independent - from which they
might receive their care.
For BMI Healthcare and every other private provider the importance of
comparable quality data was recently reinforced by the conclusions of
the Competition Commission’s market investigation into private
healthcare. From the outset of the inquiry BMI Healthcare supported the
principle that competition in the sector would be enhanced if private
hospitals produced comparable quality data, and that competition
amongst hospitals would drive up service standards. We were therefore
fully supportive when the Commission announced in April that it is
mandating the provision of greater information on the performance of
hospital operators and consultants. We wholeheartedly agree when the
Commission says that “a more transparent market with patients actively
making choices will drive hospital operators to compete on the things
that matter to patients”.
Whilst we are yet to see how the Commission will ensure that this is enacted, the private sector
continues to take its own steps. Five years ago BMI Healthcare was at the forefront of the
sector’s efforts to be more open about sharing comparable quality and pricing data when we
sponsored the launch of the Hellenic Project. Today that work has been superseded by the
Private Hospitals Information Network which is working towards publishing data that will allow
patients and commissioners to make informed choices - a challenge that the sector must now
rise to. We at BMI Healthcare will continue to play our part in these important developments,
which we believe can have a significant role in driving higher quality standards.
I remain proud, but certainly not complacent, about the quality of care our hospitals provide.
Last year BMI Healthcare invested £40m in our hospitals, supporting our committed staff and
consultants to meet the challenge of providing consistently safe, high quality care. We
constantly measure our patients’ experience, and I am pleased to note that in the three months
to the end of March 2014, 97.3% of patients independently surveyed expressed satisfaction with
their care and 97.9% said they would recommend us to others. There is however always room
for improvement, and publication of comparable quality data across the independent sector can
only help.
The information available in these quality accounts has been reviewed by the Clinical
Governance Board and I declare that as far as I am aware the information contained in these
reports is accurate. I thank all the staff whose energy and devotion to improvement is
represented here and, more importantly, in the experiences of every patient who steps across
our threshold.
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Stephen Collier
Chief Executive Officer
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Bishops Wood Hospital
Bishops Wood Hospital is a 42 bedded acute care unit, built within the grounds of Mount Vernon
Hospital, working in partnership with the NHS. The specialist facilities available at Mount
Vernon, combined with the latest in technology and on-site support services, enable our
consultants to undertake a wide range of procedures from routine investigations to complex
surgery. In the last year, the hospital has introduced a new treatment, IORT Therapy which is a
new highly effective radiotherapy treatment.
Imaging has digital Mammography, MRI and new Ultrasound equipment.
Theatres include three operating theatres one of which is used for walk-in walk-out surgery
The wards have 42 beds, 5 are within the day care unit (single sex only) the remaining rooms
offer en-suite to ensure privacy and comfort for all our patients. One High dependency unit
(Level 2)
In 2013-14 24.9% of overall work at BMI Bishops Wood Hospital was undertaken on NHS
patients
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BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Bishops Wood Hospital is registered as a location for the
following regulated services:•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Family Planning
The CQC carried out an unannounced inspection on 28th January 2014 and full compliance in
all areas inspected below was the outcome for Bishops Wood Hospital.
Standards of treating people with respect and involving them in their
care
Standards of providing care, treatment & support which meets people's
needs
Standards of caring for people safely & protecting them from harm
Standards of staffing
Standards of management
Bishops Wood Hospital has a local framework through which clinical effectiveness, clinical
incidents and clinical quality is monitored and analysed. Where appropriate, action is taken to
continuously improve the quality of care. This is through the work of a multidisciplinary group
and the Medical Advisory Committee.
Regional Clinical Quality Assurance Groups monitor and analyse trends and ensure that the
quality improvements are operationalised.
At corporate level the Clinical Governance Board has an overview and provides the strategic
leadership for corporate learning and quality improvement.
There has been ongoing focus on robust reporting of all incidents, near misses and outcomes.
Data quality has been improved by ongoing training and database improvements. New reporting
modules have increased the speed at which reports are available and the range of fields for
analysis. This ensures the availability of information for effective clinical governance with
implementation of appropriate actions to prevent recurrences in order to improve quality and
safety for patients, visitors and staff.
At present we provide full, standardised information to the NHS, including coding of procedures,
diagnoses and co-morbidities and PROMs for NHS patients.There are additional external
reporting requirements for CQC, Public Health England (Previously HPA) CCGs and Insurers
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BMI is a founding member of the Private Healthcare Information Network (PHIN) UK – where
we produce a data set of all patient episodes approaching HES-equivalency and submit this to
PHIN for publication. The data is made available to common standards for inclusion in
comparative metrics, and is published on the PHIN website http://www.phin.org.uk. This website
gives patients information to help them choose or find out more about an independent hospital
including the ability to search by location and procedure.
1. Safety
1.1 Infection prevention and control
The focus on infection prevention and control continues under
the leadership of the Group Head of Infection Prevention and
Control, in liaison with the link nurse in Bishops Wood Hospital
The focus on infection prevention and control continues under
the leadership of the Group Director of Infection Prevention and
Control and Group Head of Infection Prevention and Control, in
liaison with the Infection Prevention and Control Lead.
We have had Zero cases of MRSA bacteraemia in the last year
(NHS 1.17cases/100,000 bed days),
Zero cases MSSA bacteraemia cases /100,000 bed days,
Zero cases E.coli bacteraemia cases/ 100,000 bed days,
Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
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SSI data is also collected and submitted to Public Health England for Orthopaedic
surgical procedures. Our rates of infection are nil for:o Hips
o Knees
At Bishops wood Hospital we have systems to manage and monitor the prevention and control
of infection. These systems use risk assessments and consider how susceptible service users
are and any risks that their environment and other users may pose to them, provide and
maintain a clean and appropriate environment in managed premises that facilitates the
prevention and control of infections, pprovide suitable accurate information on infections to
service users and their visitors. Ensure that all staff and those employed to provide care in all
settings are fully involved in the process of preventing and controlling infection.
The above is monitored through quarterly reviews evidenced on yearly planner. In patient areas
complete blood cultures, peripheral line & urinary catheter on-going High Impact Intervention
care bundle audits quarterly
Oncology areas complete blood cultures, central line, & peripheral line insertion and on-going
High impact Intervention/ care bundle audits quarterly.
Theatre departments (including minor procedures) complete central line, peripheral line and
urinary catheter insertion plus pre, intra & post-operative High Impact Intervention/ care bundle
audits quarterly. The results are easily available to clinical staff.
Audits have been undertaken in Sharps safety, Hand Hygiene, Management of equipment, and
mattresses which have all achieved scores of 92% and above.
Furthermore, Hand hygiene and Aseptic Non-Touch Technique (ANTT) training is now included
in the hospital’s mandatory practical infection prevention and control training.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
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1.2 Patient Led Assessment of the Care Environment (PLACE)
We believe a patient should be cared for with compassion and dignity in a clean, safe
environment. Where standards fall short, they should be able to draw it to the attention of
managers and hold the service to account. PLACE assessments will provide motivation for
improvement by providing a clear message, directly from patients, about how the environment
or services might be enhanced. In 2013 we introduced PLACE, which is the new system for
assessing the quality of the patient environment, replacing the old Patient Environment Action
Team (PEAT) inspections.
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The assessments involve patients and staff who assess the hospital and how the environment
supports patient’s privacy and dignity, food, cleanliness and general building maintenance. It
focuses entirely onƚŚĞĐĂƌĞĞŶǀŝƌŽŶŵĞŶƚĂŶĚĚŽĞƐŶŽƚĐŽǀĞƌĐůŝŶŝĐĂůĐĂƌĞƉƌŽǀŝƐŝŽŶŽƌŚŽǁǁĞůůƐƚĂĨĨ
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1.3 Venous Thrombo-embolism (VTE)
BMI Healthcare, holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including, Bishops Wood. BMI Healthcare was awarded the Best
VTE Education Initiative Award category by Lifeblood in February 2013 and were the Runners
up in the Best VTE Patient Information category.
We see this as an important initiative to further assure patient safety and care. We audit our
compliance with our requirement to VTE risk assessment every patient who is admitted to our
facility and the results of our audit on this has shown that we are fully compliant here at Bishops
Wood Hospital reports the incidence of Venous Thromboembolism (VTE) through the corporate
clinical incident system. It is acknowledged that the challenge is receiving information for
patients who may return to their GPs or other hospitals for diagnosis and/or treatment of VTE
post discharge from the Hospital. As such we may not be made aware of them. We continue to
work with our Consultants and referrers in order to ensure that we have as much data as
possible. Bishops Wood had zero reported cases of VTE in 2013 and at time of submitting this
report
2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Patient Reported Outcome Measures (PROMs) are a means of collecting information on the
effectiveness of care delivered to NHS patients as perceived by the patients themselves.
PROMs is a Department of Health led programme.
Latest results can be found by going on the online SOLAR system provided to you by Quality
Health
For the current reporting period, the tables below demonstrate that the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing
hip replacement and knee replacement at Bishops Wood Hospital.
We have recently changed the way we work to ensure that we receive completed PROMS
questionnaire, we are asking the patient to complete their PROMs questionnaires at PreOperative assessment appointment.
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April 12 –
Mar 13
Oxford Hip Score average
Q1
Q2
Bishops
Wood
Health gain between reporting
periods
Unable to report
17.907 39.224
21.317
England
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Oxford Knee Score average
April 12 –
Health gain between reporting
Mar 13
Q1
Q2
periods
Bishops
Wood
Unable to report
18.893 34.902
16.01
England
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2.2 Enhanced Recovery Programme (ERP)
The ERP is about improving patient outcomes and speeding up a patient’s recovery after
surgery. ERP focuses on making sure patients are active participants in their own recovery and
always receive evidence based care at the right time. It is often referred to as rapid recovery, is
a new, evidence-based model of care that creates fitter patients who recover faster from major
surgery. It is the modern way for treating patients where day surgery is not appropriate.
ERP is based on the following principles:1. All Patients are on a pathway of care
a. Following best practice models of evidenced based care
b. Reduced length of stay
2. Patient Preparation
a. Pre Admission assessment undertaken
b. Group Education sessions
c. Optimizing the patient prior to admission – i.e HB optimisation, control comorbidities, medication assessment – stopping medication plan.
d. Commencement of discharge planning
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3. Proactive patient management
a. Maintaining good pre-operative hydration
b. Minimising the risk of post-operative nausea and vomiting
c. Maintaining normothermia pre and post operatively
d. Early mobilisation
4. Encouraging patients have an active role in their recovery
a. Participate in the decision making process prior to surgery
b. Education of patient and family
c. Setting own goals daily
d. Participate in their discharge planning
Here at Bishops Wood Hospital we have set up an ERP working group led by our Physiotherapy
Manager involving a multidisciplinary group of staff to ensure that we are working towards full
compliance, our results are demonstrated at our Clinical Governance and Medical Advisory
Committee meetings.
2.3 Unplanned Readmissions within 31 days and unplanned returns to theatre.
Unplanned readmissions and unplanned returns to theatre are normally due to a clinical
complication related to the original surgery.
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ϭϭ
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No trends for concern have been identified, and there is ongoing monitoring, analysis and
review by the Risk & Governance Committee on a quarterly basis to ensure that appropriate
action is taken is required to minimize the risk of complications.
3. Patient experience
3.1 Patient satisfaction
BMI Healthcare is committed to providing the highest levels of quality of care to all of our
patients. We continually monitor how we are performing by asking patients to complete a patient
satisfaction questionnaire. Patient satisfaction surveys are administered by an independent third
party.
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ϭϮ
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The management team is constantly seeking ways of improving our scores still further, patient
satisfaction is discussed at monthly Management team meetings with particular focus on lower
scoring areas such as arrival, departure, catering and discharge process.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Bishops Wood actively encourages feedback both informally and formally. Patients are
supported through a robust complaints procedure, operated over three stages:
Stage 1: Hospital resolution
Stage 2: Corporate resolution
Stage 3: Patients can refer their complaint to independent adjudication if they are not satisfied
with the outcome at the other 2 stages.
Every complaint is investigated, a written response sent to the complainant. Lessons learnt are
sought through each investigation to prevent recurrence and improve patient care quality
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4. CQUINS
Bishops Wood Hospital took part in CQUINs for London and East of England.
With VTE risk assessments, the Friends and Family test, the Safety Thermometer, and Catheter
Care Bundles were monitored for both, with additional audits on Smoking Cessation, and
Nutritional Assessments, Post-Surgical Follow-up, and Lifestyle Intervention Audit (raised BMI)
carried out for East of England.
5. National Clinical Audits
Bishops Wood was only eligible to participate in National Joint Registry audit and all joint
replacements are submitted to this. BMI hospital data is from page 196 onwards in attached
latest NJS report.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
•
•
•
•
•
•
On-going engagement with NHS commissioners, enhancing patient choice, service
delivery, monitored and measured through quality indicators
Improvement in the patient satisfaction scores and friends and family recommendation
for all areas.
Continued audit compliance, ensuring that healthcare acquired infection remains at zero
Audit Compliance with care bundles, ensuring effective implementation
Delivery of BMI Clinical Strategy and 6C’s as part of the Chief Nurse initiative from the
Francis enquiry
Rapid Access Patient Pathway for cancer patients, Breast mammography/ultrasound
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Bishops Wood Hospital for the reporting period.
Unit
Value
and
Banding
Reporting Periods
(at least last two
reporting periods)
Oct 11 – Jun 13
National
Average
Highest National
Score
Lowest National
Score
1.0006
1.1822
0.6735
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ϭϱ
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8.2 The Bishops Wood Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
0.083
0.157
0.014
National
Average
Highest National
Score
Lowest National
Score
-8.738
8.172
-15.918
(ii) Varicose vein surgery
Unit
N/A
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
Please note that the data provided by HSCIC did not have any data for reporting purposes.
(iii) Hip replacement surgery
Unit
71
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
21.280
24.684
17.214
(iv) Knee replacement surgery during the reporting period.
Unit
Reporting Periods
National
Highest National
Lowest National
(at least last two
Average
Score
Score
reporting periods)
94
Apr 12 – Mar 13
15.99
20.37
12.2
The Bishops Wood Hospital considers that this data is as described for the following reasons
(insert reasons).
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ϭϲ
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8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
(Bishops Wood Hospital) within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
0%
Reporting Periods
(at least last two
reporting periods)
Apr 11 - Mar 12
National
Average
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
The Bishops Wood Hospital considers that this data is as described for the following reasons is
well below the national average.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
Bishops Wood Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
0.5%
Reporting Periods
(at least last two
reporting periods)
Apr 11 – Mar 12
National
Average
Highest National
Score
Lowest National
Score
10.01
14.51
5.54
The Bishops Wood Hospital considers that this data is as described for the following reasons as
it is well below the national average.
8.4 The Bishops Wood Hospital responsiveness to the personal needs of its patients during the
reporting period.
Unit
96.4%
Reporting Periods
(at least last two
reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
The Bishops Wood Hospital considers that this data is as described for the following reasons is
above the national average.
8.5 The percentage of patients who were admitted to Bishops Wood Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
96.65%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
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The Bishops Wood Hospital considers that this data is as described for the following reasons as
just above the national average these results were achieved through monthly audits with focus
on importance of completing all risk assessments.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within Bishops Wood
Hospital amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
17.3
30.8
0
Bishops Wood Hospital will continue to achieve compliance through strict adherence to Infection
Prevention and Control policies, ensuring antibiotic prescribing protocol is followed according to
best practice.
8.7 The number and, where available, rate of patient safety incidents reported within the
Bishops Wood Hospital during the reporting period, Number of patient safety incidents reported
Unit
84
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
44.55
1,810
0
Rate of patient safety incidents reported (Incidents per 100 Admissions)
Unit
2.372
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
7.76
30.95
1.68
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
0.64
28
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100
Admissions)
Unit
0%
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
0.9
2.9
0.0
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Bishops Wood Hospital has a robust reporting structure, all incidents are discussed at monthly
Clinical Mangers Meeting, Bi-monthly Clinical Governance Meetings and Quarterly Medical
Advisory Meetings with learned outcomes shared.
8.8 The percentage of staff employed by BMI Bishops Wood during the reporting period, who
would recommend the Bishops Wood as a provider of care to their family or friends.
Unit
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
%
64.58
9. Non-Mandatory Quality Indicators
Highest National
Score
Lowest National
Score
96.43
33.73
9.1 The percentage of patients who received care as inpatients or discharged from A &E during
the reporting period, who would recommend Bishops Wood Hospital as a provider of care to
their family or friends.
Unit
98.9%
Reporting Periods
(at least last two
reporting periods)
Jun 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
Bishops Wood Hospital considers that this data is as described for the following reasons as well
above the Highest National score
The percentage of patients who received care as in-patients who would recommend BMI
Bishops Wood Hospital as a provider of care to their family and friends is 99%. This data is
collected and reported through the Patient Satisfaction Questionnaire that is given to all patients
at the hospital and is from a 31% response rate.
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