Chief Executive’s Statement
I am pleased to welcome you to our Quality Accounts 2015.
Now in their sixth year, Quality Accounts continue to provide a truly
objective metric for us, and others, to gauge the quality of our 59
hospitals and the services they provide against a broad range of
criteria.
The past year has seen another step change in the way healthcare
providers are externally challenged on the quality they provide.
Following a spate of high profile controversies around patient safety,
the Care Quality Commission, the UK’s health regulator, has
introduced a new inspection regime designed to raise standards.
No healthcare provider can afford to be complacent and whilst I
believe BMI’s hospitals provide safe and effective care, we should
always be striving for improvement.
To this end we recently introduced a new Quality Strategy, which
articulates how we will provide the best possible care and strive for continual improvement, and live up to
our brand promise to be “serious about health, passionate about care”. Its four core themes – safety,
clinical effectiveness, patient experience and quality assurance – provide our staff with the platform to
consistently deliver the care patients, their insurers, and commissioners expect and deserve.
BMI hospitals have been enthusiastic participants in the pilot programme of the new CQC inspection
regime for private providers, and to ensure our facilities are prepared we have developed a selfassessment tool to enable hospitals to compare their perceptions of themselves with those of the external
inspectors. The rigorous inspection process itself also underpins the sharing of best practice between
hospitals which further drives improvement and consistency.
BMI Healthcare strives to provide the best care but the ultimate arbiters of whether we succeed are our
patients. We are committed to monitoring every aspect of the care we provide, and the results of the
detailed questionnaires we ask patients to complete inform improvement. We aim to provide a consistent,
high quality patient experience and an environment that empowers our consultants to excel. Providing a
dependably high quality of care requires constant focus on improvement; the most recent independent
research conducted for BMI shows that over 98% of our patients rate their care as excellent or very good.
The information available here 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. Finally I would like to thank all
the staff whose application, professionalism and ceaseless commitment to improvement is recognized
here and in the positive experiences of the patients we care for. Since I joined BMI late last year, I have
witnessed this firsthand on my many visits to our hospitals and I am committed to ensuring we build on
that success.
Jill Watts, Group Chief Executive
Hospital Information
BMI Bath Clinic has 67 beds with all rooms offering the privacy and comfort of en-suite facilities,
satellite TV and telephone. The hospital has 3 theatres, two major and one minor, and a
dedicated endoscopy unit.
We also benefit from a full range of diagnostic imaging equipment including fixed site 64-slice
CT, ultrasound, mammography and x-ray. In the last year we have replaced our MRI scanner
with the very latest specification mode.
Year to date, NHS patients have accounted for 50.7% of our overall patient numbers.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Bath Clinic 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 1st May 2013 and found BMI Bath Clinic to
be compliant with all outcomes inspected:
Treating people with respect and involving them in their care
Providing care, treatment & support that meets people's needs
Caring for people safely & protecting them from harm
Staffing
Quality and suitability of management
BMI Bath Clinic 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
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 Director of Infection Prevention and
Control and Group Head of Infection Prevention and Control, in
liaison with the Infection Prevention and Control Lead at BMI
Bath Clinic.
We have had: • Zero MRSA bacteraemia cases/100,000 bed days
• Zero MSSA bacteraemia cases /100,000 bed days
• Zero E.coli bacteraemia cases/ 100,000 bed days
• Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
SSI data is also collected and submitted to Public Health England for Orthopaedic surgical
procedures. Submission of this data commenced on 1st January 2015 and our rates of infection
for the period Jan-March 2015 are;
o
o
Hips 0% (67 hip replacements)
Knees 0% (35 knee replacements)
Surveillance is ongoing and continuous for these procedure categories.
At BMI Bath Clinic there is an Infection Prevention and Control audit programme in which every
clinical department participates. These regular audits provide feedback to staff on the quality of
their IPC practice and include hand hygiene, standard infection prevention and control
precautions as well as aseptic practice.
Hand hygiene practice and technique are both audited bi-monthly and, although compliance is
high (95% and 98% respectively); additional hand gel dispensers have been placed at point of
care in order to promote and sustain good hand hygiene practice. This action has been further
supported with the promotion of personal hand gel dispenser use amongst staff as well as the
planned installation of four new clinical hand-washing stations on Claverton Ward.
To reduce the risks of HCAIs, High Impact Intervention Care Bundles are applied for the
following:
•
•
•
Peripheral venous cannulation
Urinary catheters
Surgical site infection prevention
Compliance to the Care Bundles is audited quarterly as part of the IPC Audit Schedule and
compliance was 100% for all three categories in the last audit quarter (January-March 2015).
Staff undertake yearly training updates on hand hygiene, aseptic non-touch techniques and
application of the Care Bundles via the mandatory training programme on BMiLearn. This
involves a combination of e-Learning and face to face training which is supported by practical
assessment in the working environment. Currently71% of clinical staff have successfully
completed their ANTT competences, whereas 93% have completed hand hygiene training.
Environmental cleanliness is also an important factor in infection prevention and control, and our
patients rate the cleanliness of our facilities highly:
Patient satisfaction - cleanliness
% excellent and very good scores (Apr 2014 - Mar
2015)
90
70
50
30
10
Bathroom cleanliness
Room cleanliness
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.
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 on the care environment and does not cover clinical care provision or how well staff are
doing their job.
The results show how hospitals are performing nationally and locally.
PLACE results 2014
Category
Result
Cleanliness
98.87%
Food & hydration
97.09%
Privacy, dignity & wellbeing
92.24%
Condition, appearance & maintenance
91.82%
The 2014 audit identified that we needed additional signage around the hospital, which was
addressed following the audit.
The 2015 PLACE audit is due to take place in June 2015.
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 BMI Bath Clinic. BMI Healthcare was awarded the Best
VTE Education Initiative Award category by Lifeblood in February 2013 and was the runner 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 assess every patient who is admitted to our facility
and the results of our audit has shown 90.3% compliance. We are in the process of identifying
VTE champions at ward level to ensure that, moving forward, we can demonstrate 100%
compliance. Furthermore, daily documentation audits will be undertaken by clinical staff at ward
level as a way of self-assessing documentation compliance.
BMI Bath Clinic 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.
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.
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 BMI Bath Clinic.
April 14 – September 14
BMI Bath Clinic
England
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
“*”
“*”
“*”
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
April 14 – September 14
BMI Bath Clinic
England
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
“*”
“*”
“*”
19.401
36.103
16.702
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
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. Reducing 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
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 to 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
BMI Bath Clinic is achieving these principles and the average length of stay for NHS hip and
knee patients is 3.45 and 3.7 days respectively, year to date.
In January 2015, we introduced Surgical Pre-Assessment (SPA) appointments, which have
enabled us to increase the number of patients who have face-to-face pre-operative assessment.
This provides us with the opportunity to introduce the multi-disciplinary team into the patient
pathway at an earlier stage.
Additionally, we are currently considering the best option for BMI Bath Clinic patients in terms of
the introduction of joint schools.
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.
We believe that the improvements we have made in this area during the last year are in part
attributable to the appointment of a dedicated Infection Prevention and Control Lead.
While the 2015 data shows a marginal increase compared to 2014, due to the unit of
measurement, this does not give significant cause for concern.
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.
Patient satisfaction - % excellent and very good scores
(Apr 2013 – Mar 2014 and Apr 2014 – Mar 2015)
In 2014 we embarked on a project to establish what makes the difference between patients
marking us as “very good” and “excellent”. We carried out targeted on-line focus groups with
previous patients and delivered their feedback to staff through coaching sessions. Staff were
able to watch the video clips of our patients talking about the care they had received, which we
found to be an extremely powerful way of motivating staff and enabling them to evaluate what
they could do as individuals to provide the tailored care that our patients seek.
Our patient satisfaction score has increased each month since the delivery of the coaching
sessions.
We are now focusing on maintaining this improvement and looking closely at our departure
process in particular where we feel there is the greatest room for improvement.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Bath Clinic 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.
We continue to see a trend in complaints relating directly to the Consultant rather than to the
hospital. Rather than simply advising the complainant that they will have to take this up with the
Consultant concerned, our approach is to facilitate a response from the Consultant within our
timescales and summarise this for the complainant. We then offer to meet with the complainant
so that they have the opportunity to speak to us in person, if they wish. We also offer to
facilitate a meeting between them and the Consultant in order that we can act as a neutral party
and do our utmost to ensure that the complainant’s questions are answered.
We promote a culture of empowering staff to react to complaint triggers at the time either by
seeking a resolution themselves or by escalating the problem. This enables us to react prior to
the problem becoming a written complaint. In addition, our Meet our Team initiative is currently
in its development stage. Once in place, this will offer all service users the opportunity to meet
with any member of the Senior Management Team to give feedback. We want our patients and
their visitors to feel that they are in an environment where feedback of any sort is encouraged,
responded to and learnt from.
4. CQUINs
2014-2015
BMI Bath Clinic’s CQUINs activity for this period is as follows:
•
Friends & Family: 100% of NHS patients responding stated they would recommend BMI
Bath Clinic to their friends and family for the period March 2014-February 2015.
•
VTE assessment: We audit our compliance with our requirement to VTE risk assess
every patient who is admitted to our facility and the results of our audit has shown 90.3%
compliance. We are in the process of identifying VTE champions at ward level to ensure
that, moving forward, we can demonstrate 100% compliance. Furthermore, daily
documentation audits will be undertaken by clinical staff at ward level as a way of selfassessing documentation compliance.
•
Mobilisation: Audits confirm that we are mobilizing 100% of patients within 24 hours of
surgery.
We are awaiting sign off of our 2015-2016 local CQUINs.
5. National Clinical Audits
BMI Bath Clinic was only eligible to participate in the National Joint Registry audit and all joint
replacement data is submitted to this. BMI hospital data is from page 196 onwards in attached
latest NJS report.
NCEPOD studies are currently looking at non-invasive ventilation and gastrointestinal bleeds.
Any relevant data will be submitted.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
1. We have recently introduced an enhanced walk-in, walk-out pathway for patients
undergoing minor surgical procedures. We now have dedicated nursing staff for the pre
and post-operative periods, while the patient continues to be guided through the perioperative period by the theatre staff. Dedicated male and female waiting areas situated
within the ward have also been allocated. Our next priority is to introduce additional
procedures into this pathway.
2. We are currently focusing on our pre-admission clinic in order to meet our local target of
pre-assessing 100% of our patients, either face-to-face or over the phone, depending on
the procedure they are listed for. Having introduced our Surgical Pre-Assessment clinics
in January 2015, we have already shown a marked improvement in this aspect of our
care.
3. Our patient satisfaction results indicate that there is room for improvement in our
discharge processes. To this end, we are reviewing this part of our patients’ pathway in
respect of our Daycare and Inpatient wards, with our initial focus aimed at after-care
advice.
4. We are currently developing “Meet our Team” sessions, which will enable any service
user to attend the hospital for drop-in sessions with the Senior Management Team, both
pre and post-operatively.
8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for BMI Bath Clinic for
the reporting period.
Unit
Data not
available
Reporting Periods
(at least last two
reporting periods)
Oct 2012 – Jun 2014
National
Average
Highest National
Score
Lowest National
Score
0.9987
1.1849
0.58345
8.2 BMI Bath Clinic’s patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
Data not
available
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
0.0786
0.278
-0.112
National
Average
Highest National
Score
Lowest National
Score
-7.395
-1.957
-12.571
National
Average
Highest National
Score
Lowest National
Score
21.542
28.6
9.714
(ii) Varicose vein surgery
Unit
Data not
available
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
(iii) Hip replacement surgery
Unit
Data not
available
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
(iv) Knee replacement surgery during the reporting period.
Unit
Data not
available
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
16.641
24.429
5.833
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
BMI Bath Clinic within 28 days of being discharged from a hospital which forms part of the
hospital during the reporting period.
Unit
Reporting Periods
(at least last two
reporting periods)
Apr 11 - Mar 12
0%
National
Average
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
From October 2014, BMI Bath Clinic no longer treats patients under the age of 16.
8.3 (ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the BMI Bath Clinic within 28 days of being discharged from a hospital which forms part of the
hospital during the reporting period.
Unit
0.15%
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
BMI Bath Clinic considers that this data is as described for the following reasons:
•
Unplanned readmissions have been due to a number of known potential clinical
complications related to the original surgery including; pain, poor mobility, urinary
retention, constipation, additional surgical intervention, observation of wound, washout of
wound and wound infection.
BMI Bath Clinic intends to take the following actions to improve this percentage, and so the
quality of its services, by:
•
•
•
•
Continuing to undertake root cause analysis for all post-operative wound infections to
identify contributing factors, improve practice where possible and share learning.
Continue to follow up all post-surgical patients post discharge with a courtesy call within
forty-eight hours to check wellbeing and provide advice and support.
Continue to ensure that all patients have a point of contact should they experience
problems post discharge.
Ensure that patients are supported with adequate information about potential postoperative pain, symptoms and complications from pre-admission to post-discharge.
8.4 BMI Bath Clinic’s responsiveness to the personal needs of its patients during the reporting
period.
Unit
97.84%
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
BMI Bath Clinic considers that this data is as described for the following reasons:
•
•
•
Appropriate healthcare professional to patient ratio
Single occupancy rooms to facilitate private discussions
Rapid response to call bells
BMI Bath Clinic intends to focus on the feedback we received in our patient focus groups (2014)
to maintain and improve this score, and so the quality of its services, by delivering tailored care
to each patient that takes into account the ancillary aspects of our care, which we know are
important to our patients, as well as the fundamental parts of our service.
8.5 The percentage of patients who were admitted to BMI Bath Clinic and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
90.3%
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Jan 15
National
Average
Highest National
Score
Lowest National
Score
95
100
87
BMI Bath Clinic considers that this data is as described as we are now auditing a far greater
percentage of patients’ notes thus our data is now representative.
BMI Bath Clinic audits compliance with the requirement to VTE risk assess every patient who is
admitted to our facility. We are in the process of identifying VTE champions at ward level to
ensure that, moving forward, we can demonstrate 100% compliance. Furthermore, daily
documentation audits will be undertaken by clinical staff at ward level as a way of self-assessing
documentation compliance.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within BMI Bath
Clinic amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
14.7
37.1
0
BMI Bath Clinic considers that this data is as described for the following reasons:
•
Robust infection prevention and control practices integral to everyday practice
•
Daily Lead Pharmacist review of antibiotic prescribing
BMI Bath Clinic intends to maintain this rate by achieving consistency of practice and standards.
8.7 The number and, where available, rate of patient safety incidents reported within BMI Bath
Clinic during the reporting period, and the number and percentage of such patient safety
incidents that resulted in severe harm or death.
Number of patient safety incidents reported
Unit
260
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
Lowest National
Score
20
139
0
Rate of patient safety incidents reported (Incidents per 100 Bed Days)
Unit
9.72
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
Lowest National
Score
3.589
7.496
0.0245
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
40.2
97
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)
Oct 13 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
BMI Bath Clinic considers that this data is as described for the following reasons:
•
Robust reporting culture and daily promotion of patient safety
BMI Bath Clinic intends to maintain this ratio by continuing to promote the identification of
patient safety issues and to manage and reduce risk of actual harm.
8.8 The percentage of staff employed by BMI Bath Clinic during the reporting period, who would
recommend BMI Bath Clinic as a provider of care to their family or friends.
Unit
Reporting Periods
(at least last two
reporting periods)
2014
96%
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
BMI Bath Clinic considers that this data is as described for the following reasons:
•
•
We invest in and promote staff wellbeing
We implement specific action plans following our staff surveys
9. Non-Mandatory Quality Indicators
9.1 The percentage of patients who received care as inpatients or discharged from A&E during
the reporting period, who would recommend BMI Bath Clinic as a provider of care to their family
or friends.
Unit
87.25%
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
BMI Bath Clinic considers that this data is as described for the following reasons:
We have consistently achieved >95% overall quality of care rating in our patient satisfaction
feedback for the reporting period. It would therefore be reasonable to assume that this would
be reflected in the Friends & Family recommendation question.