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 Bishops Wood Hospital The Bishops Wood Hospital opened on 27th March 1990 and is one of the BMI hospitals in a partnership with the NHS that rents land from the local trust. Bishops Wood Hospital shares the site with Mount Vernon Hospital, a world-renowned centre for cancer treatment which falls within the East of England cancer centres. • No of beds: 30 O/N, 5 bedded day unit, 7 chemo day rooms. • Theatres: 2 + 1 minor procedures. • Key services: o Physiotherapy, Imaging, Pharmacy, complimentary / cancer therapies, 8 consulting rooms incl. dedicated Ophthalmology and ENT / Gynaecology. • Specialty mix: o Chemotherapy / Oncology, Palliative Care / End of Life, Orthopaedics, Paediatrics, Gynaecology, ENT, Ophthalmology • Activity overview: o • Oncology 40%; Ortho 30.7%. Payor split: Insured: 68.8% (BUPA 26.6%, AXA PPP 17.9%) Self pay: 6.6% NHS 24.5% NHS Landscape Bishops Wood Hospital also shares the site with the Mount Vernon Diagnostic Treatment Centre, which opened in 2010. This building houses 4 state-of-the-art operating theatres to carry out elective surgery as well as housing its own Outpatients Services Department, a spacious waiting area and Costa Coffee Shop. Bishops Wood Hospital is approximately 20 minutes drive from the Hillingdon Hospital and 15 minutes drive to Watford General Hospital. The hospital’s consultants are predominantly made up of Hillingdon consultants but recently there has been an encouraging move from the Watford consultants mostly working at Spire Bushey who have started to work to Bishops Wood. 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 th The CQC carried out an unannounced inspection on 28 January 2014 and found; 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. There has been development of 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 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 at Bishops Wood Hospital. We have had: • 0.000 MRSA bacteraemia cases/100,000 bed days • 0.000 MSSA bacteraemia cases /100,000 bed days • 0.000 E.coli bacteraemia cases/ 100,000 bed days • 0.000 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. Our rates of infection are; o Hips o Knees BMI Bishops Wood Hospital has been audited by the hospitals IPC department in regards to hospitals care bundles, the results are as follows; Care Bundle Score Peripheral line insertion (17) 100% Peripheral line ongoing care 100% SSI Pre op care 70% SSI Intra operative care (20) 100% SSI Post op care 100% Blood Culture (4) 100% Catheter Insertion (8) 100% Catheter on going care 100% In order to improve our pre-operative care bundle, the hospitals improvement action plan is to ensure staff document that in the ward admission pre op showering has been carried out by the patient. Hand hygiene observational audit Department Bare below the Elbows Total Compliance Wards 100% 85.7% OPD Not Completed Not Completed Physiotherapy 100% 100% Imaging 100% 100% Theatre 100% 100% As highlighted from the hand hygiene audit, BMI Bishops Wood has recognised the result from the wards and is in the process of developing a strategy to improve this. BMI Bishops Wood has introduced an awareness programme to ensure staff are appraised and compliant in the delivery of care to the service users. BMI Bishops Wood has provided training on ANTT/ SSI care bundles and also infection prevention control module exercises for staff to complete and also mandatory practical sessions on correct hand washing and aseptic technique which staff are assessment to ensure the standards for practice are met. Include any focused activities on hand hygiene, aseptic non touch technique and other infection prevention activities. Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly. 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 will show how hospitals are performing nationally and locally. Results of the hospitals PLACE inspection results are as follows; • Overall the standard of cleanliness is excellent and generally very tidy • Decoration of the common areas is good however some of the bathrooms need modernizing. • Car park was very busy; however Stefan was doing an excellent job of managing the space • Grounds maintenance has improved from last year, the flower baskets are nice and good hedging and borders. • All staffs are dressed smartly, very friendly and are polite. • There is a wide range of food and drink available. • The building is bright and clean and welcoming. Our Place audit highlighted areas that can contribute to enhancing the service provided, through ensuring that environmental factors are improved such as the clear and visible signage to a couple of departments in the hospital and also that regulation of temperature as it was audited that it was too warm in a few patient rooms. 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 Hospital. 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 98%- 100% which has been recognized the DoCs. Our intention to retain and further improve BMI Bishops Wood percentage is firstly through our monthly audits. The audits provide insight into the various departments of the hospital which are used to monitor and continually review. As the hospital review’s the data, we are able to develop trends to analyze and gain a greater comprehension into the standards of service performed by the staff. Creating this framework allows BMI Bishops wood to visualize data formerly accrued and connect it to the current structure/ guideline the staff work within, the audits assists in revealing the specific focus area that require intervention to improve the current service operations. BMI Bishops Wood achieves this by creating staff forums, in these sessions the management team highlight target areas, which collectively as a multidisciplinary team are required to develop in. The staff are supported in achieving this through training, interim reviews and also given the opportunity to ask the management team when unsure during the probationary trial of the new working standards. Staff are encouraged to communicate views and experience during the trial process in order to provide a detailed understanding from the perspective of the staff, before introducing a new permanent work instruction. BMI 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. The data comparatively emphasizes that between 2014-15 the number of clinical incidents with an adverse outcome has dropped by 0.4617 whilst non adverse outcomes have increased by 0.031. The reason for these changes is as a hospital we have encouraged on a local scale to report incidents and issues that have occurred within the hospital; this explains the increase of non-adverse outcomes. The other reason is staff have been trained in the correct procedure for filling out incidents forms, with an focus on the correct categorization of incidents, which is highlighted on the graph, the decrease in the number of adverse outcomes. 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, due to low numbers of less than 30 patients, BMI Bishops wood was unable to present figures to comment on the comparison of hospital and NHS data. One of the hospitals current initiatives for capturing this data is by changing the process of patient’s care pathway when visiting BMI Bishops Wood. There is a local hospital drive that as patients attend pre-assessment clinic, staff are asked to collect information at this point and also at the postoperative phase of the patients hospital pathway. This local initiative aims to correct this problem and also gain the necessary information to benchmark against current trends in comparison to the NHS. Oxford Hip Score average April 14 – September 14 Q1 Q2 18.16 40.081 Health gain between reporting periods BMI Bishops Wood England 21.922 Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved. Oxford Knee Score average April 14 – September 14 Q1 Q2 19.401 36.103 Health gain between reporting periods BMI Bishops Wood England 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. 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 co-morbidities, 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 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 At BMI Bishops Wood Hospital the ERP is currently available and used as part of the service towards the patients and users. Our ERP committee has regular quarterly meetings to discuss current factors in association with the programme and possible avenues for improvements that could be made in order to enhance the programme and it’s ALOS score. 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. Local narrative on data and any improvement plans etc. 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. From BMI Bishops Wood PSQ’s there is evidence of exceeding the targets from other BMI sites, regarding the patients level of expectation of the serivce and satisfaction of the care provided. The main areas that evdience this are the patients arrival process and discharge procedures, nursing care and hospital accomodation. Unfortunately from the results given by patients, BMI Bishops Wood catering facilities and quality of care either met or the results were below the target line in comparison to other BMI hopitals. Our improvement plan for the quality of care is to recognise the target areas to which the lowest percentage came from. Then as a hospital, we aim to carry out department performance review and quality care audits, to identify the specific areas for development. In order to improve the department standards, training will be given to staff, focus sessions will be arranged to communicate the facets of staff practice that need to be changed, to provide a more effective and efficient standard of service for the patients. To improve our current level of service at BMI Bishops Wood Hospital, one of the focus points of the service is currently catering. From the percentages highlighting catering is 87.4%, the future development of this area, as part of BMI corperate reform, will be to intergret with an external catering contractor for the hospitals catering and hospitality services. Another key area for service improvement at BMI Bishops Wood Hospital is the departure process, as part of the patient pathway. Ways in which, as a hospital, hopes to achieve this will be to ensure the latter stage of the patients experience is not hasted; consultant post-operative assessment, nursing discharge and depature from hospital this will be communicated to and led on a macro management scale by the staff, with oversight from the senior mangement team monitoring progress. 3.2 Complaints In addition to providing all patients with an opportunity to complete a satisfaction survey BMI Bishops Wood Hospital 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. Add table from QA spreadhseet - do narrative on main themes of complaints and actions to improve. 4. CQUINS Narrative on local activity and results 5. National Clinical Audits BMI Bishops Wood Hospital 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. Use this if appropriate with your narrative on the data and any improvement plans. 6. Research No NHS patients were recruited to take part in research. 7. Priorities for service development and improvement As part of our service developments and improvements, the hospital Oncology unit is currently under a refurbishment. The development project aims to upgrade the bedroom and bathroom facilities replacing the room’s carpet with vinyl. The room will instead of a bed, have a fully reclining arm chair to ease the patient in the administration of chemotherapy. The room has been designed to encapsulate and provide a relaxing and tranquil environment. To improve and enhance the scope of facilities on offer for users, BMI Bishops Wood intends establish partnership with NHS cancer and also include the use of robotic radiosurgery/ brachytherapy. 8. Mandatory Quality Indicators **Please note unable to confirm unit scores** 8.1 The value of the summary hospital-level mortality indicator (SHMI) for the (Bishops Wood Hospital) for the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 0.9987 1.1849 0.58345 reporting periods) Value Oct 2012 – Jun 2014 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood)(intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.2 The (Bishops Wood Hospital) patient reported outcome measures scores for (i) Groin hernia surgery Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 0.0786 0.278 -0.112 reporting periods) Number Apr 14 – Sept 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). (ii) Varicose vein surgery Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score -7.395 -1.957 -12.571 reporting periods) Number Apr 14 – Sept 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). (iii) Hip replacement surgery Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 21.542 28.6 9.714 reporting periods) Number Apr 14 – Sept 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). (iv) Knee replacement surgery during the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 16.641 24.429 5.833 reporting periods) Number Apr 14 – Sept 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the (BMI Bishops Wood Hospital) within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 11.45 14.35 7.96 reporting periods) % Apr 11 - Mar 12 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of the (name of hospital) within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 10.01 14.51 5.54 reporting periods) % Apr 11 – Mar 12 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.4 The (BMI Bishops Wood Hospital) responsiveness to the personal needs of its patients during the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 68.7 85 54.4 reporting periods) % 2013-2014 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.5 The percentage of patients who were admitted to (BMI Bishops Wood Hospital) and who were risk assessed for venous thromboembolism during the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 95 100 87 reporting periods) % Apr 14 – Jan 15 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the (BMI Bishops Wood Hospital) amongst patients aged 2 or over during the reporting period. Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 14.7 37.1 0 reporting periods) 0 Apr 13 – Mar 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.7 The number and, where available, rate of patient safety incidents reported within the (BMI Bishops Wood Hospital) 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 Reporting Periods National Highest National Lowest National (at least last two Average Score Score 20 139 0 reporting periods) Number Oct 13 – Sep 14 Rate of patient safety incidents reported (Incidents per 100 Bed Days) Unit Reporting Periods National Highest National Lowest National (at least last two Average Score Score 3.589 7.496 0.0245 reporting periods) Rate Oct 13 – Sep 14 Number of patient safety incidents that resulted in severe harm or death Unit Reporting Periods National Highest National Lowest National (at least last two reporting Average Score Score periods) Number Oct 13 – Sept 14 40.2 97 0 Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100 Admissions) Unit Reporting Periods National Highest National Lowest National (at least last two reporting Average Score Score 0.3 2.4 0.0 periods) % Oct 13 – Sept 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 8.8 The percentage of staff employed by the (BMI Bishops Wood Hospital) during the reporting period, who would recommend the (BMI Bishops Wood Hospital) as a provider of care to their family or friends. Unit Reporting Periods National Highest National Lowest National (at least last two reporting Average Score Score 64.58 96.43 33.73 periods) 81 2014 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (BMI Bishops Wood Hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions). 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 the (BMI Bishops Wood Hospital) as a provider of care to their family or friends. Unit Reporting Periods National Highest National Lowest National (at least last two reporting Average Score Score 66.23 94.38 35.63 periods) % Jun 13 – Jan 14 The (BMI Bishops Wood Hospital) considers that this data is as described for the following reasons (insert reasons). The (name of hospital) (intends to take/has taken) the following actions to improve this (percentage/proportion/score/rate/number), and so the quality of its services, by (insert description of actions).