BMI Healthcare
Serious about health. Passionate about care.
BMI Clementine Churchill Hospital Quality Accounts
April 2014 to March 2015
Chief Executive’s Statement
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
1
BMI Healthcare
Serious about health. Passionate about care.
Chief Executive 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
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
2
BMI Healthcare
Serious about health. Passionate about care.
.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
3
BMI Healthcare
Serious about health. Passionate about care.
Hospital Information
BMI The Clementine Churchill Hospital provides services to adults and children from 3 years of
age both private and NHS patients. The hospital has 122 operational beds with all rooms
offering the privacy and comfort of en-suite facilities, Freeview TV, Wi-Fi and telephone. The
hospital has five theatres, a minor surgery operating, endoscopy suite, a level III Intensive Care
Unit and offers a self-pay, walk-in Emergency Care Centre, open 7 days a week, from 8am 10pm.
The hospital has committed to a rolling programme of refurbishment. This includes public areas
and patient bedrooms. We also are near completion of a brand new Endoscopy Unit which we
aim to open in June 2015.
We currently work with a range of payors, including CCG’s. NHS patients have the opportunity
to use our services under choose and book, we also work with local trusts in fulfilling spot
contract work, to ensure patient waits are kept to a minimum. NHS patients make up 25% of
our overall workload.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Clementine Churchill Hospital is registered as a location for
the following regulated services:-
•
•
•
Diagnostic and/or screening services
Surgical procedures,
Treatment of disease, disorder or injury,
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
4
BMI Healthcare
Serious about health. Passionate about care.
The CQC did not carry out an inspection between April 2014 and March 2015. The last
inspection was an unannounced inspection on 27 January 2014 and found the following:Consent to care & treatment
Met this standard
Care and welfare of people using the service
Action needed
Safeguarding people who use the service from abuse
Action needed
Cleanliness and infection control
Action needed
Management of medicines
Action needed
Safety and suitability of premises
Action needed
Safety, availability and suitability of Equipment
Action needed
Staffing
Action needed
Supporting workers
Action needed
Assessing / monitoring the quality of service provision
Action needed
Records
Action needed
The CQC identified 10 outcomes that had a minor or moderate effect on patient care. As a
result of which the Hospital Management team developed a robust action plan covering all 10
outcomes. All actions have since been completed to ensure processes are embedded and
adhered to, and that our patients all receive a high quality care at every stage of their journey.
The Clementine Churchill 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, Clinical Governance and Medical Advisory Committees.
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.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
5
BMI Healthcare
Serious about health. Passionate about care.
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
under the
Prevention
Prevention
Prevention
Hospital.
on infection prevention and control continues
leadership of the Group Director of Infection
and Control and Group Head of Infection
and Control, in liaison with the Infection
and Control Lead The Clementine Churchill
We have had: •
0 reported cases of MRSA bacteraemia per 100,000 bed
days in the last year (NHS 1.17cases/100,000 bed
days).
•
0 reported MSSA bacteraemia cases /100,000 bed days
•
0 reported E.coli bacteraemia cases/ 100,000 bed days
•
0 cases of hospital apportioned Clostridium difficile in the last 12 months.
•
We are in the process of collecting SSI data for submission to Public Health England for
orthopaedic surgical procedures. Our rates of infection are 0% for both hips and knees.
Infection prevention and control audits are undertaken in all areas on a monthly basis. There
is a renewed focus on hand hygiene and ANTT training and audits which are then collated
at reported at quarterly Infection Prevention and Control Committee meetings.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
6
BMI Healthcare
Serious about health. Passionate about care.
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 PLACE audit for Clementine Churchill Hospital was carried out in May 2014 and involved
four patient assessors and four staff split into 2 teams, with results as follows:-
Privacy, Dignity
Condition, Appearance
& Wellbeing
& Maintenance
88.79%
87.73%
91.97%
93.87%
99.00%
97.47%
Organization
Cleanliness
Food
National level score
97.25%
Clementine Churchill
99.76%
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
7
BMI Healthcare
Serious about health. Passionate about care.
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, The BMI Clementine Churchill 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 a 100% compliance rate.
The Clementine Churchill 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. These figures from 2014-15 show that VTE
incident numbers remain very low. Any incidents are investigated and a root cause
analysis carried out.
Numbers
Rate per 100 Admissions
DVT
4
0.037
PE
1
0.009
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
8
BMI Healthcare
Serious about health. Passionate about care.
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 are 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 The Clementine Churchill Hospital.
Unfortunately there were less than 30 patients who went through this pathway during the
reporting period, and so no score has been provided.
Oxford Hip Score average
April 14 – September 14
Q1
Q2
Health gain between reporting
periods
BMI Clementine Churchill
NA
NA
NA
18.16
40.081
21.922
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
Oxford Knee Score average
April 14 – September 14
Q1
Q2
Health gain between reporting
periods
BMI Clementine Churchill
NA
NA
NA
19.401
36.103
16.702
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
9
BMI Healthcare
Serious about health. Passionate about care.
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
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
We have seen our average length of stay reduce over the past year through having a
dedicated team focusing on this which report any deviations to length of stay and
reasons at daily ‘Comm Cells, discussing at weekly meetings, reporting any delayed
discharges on Sentinel to monitor trends, working with consultants to review their
booking process (now booked for 3 days instead of 5), and setting up Joint Schools.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
10
BMI Healthcare
Serious about health. Passionate about care.
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.
Comparing these scores it can be seen that readmission rates have gone down whilst
returns to theatre have increased slightly. Reasons for these have been monitored through
our monthly clinical governance committee meetings, and no adverse trends identified.
Furthermore these rates are comparable to other BMI sites of a similar size.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
11
BMI Healthcare
Serious about health. Passionate about care.
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.
We have 2 working groups focussing on the key areas for improvement of:Clinical - Administration/Nursing/Discharge, and
Non-clinical - Accommodation/Catering
These groups meet monthly to discuss actions required and progress taken is then
reviewed at monthly Management Team meetings. The graph above shows that
improvements have been made in most areas over the past year.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
12
BMI Healthcare
Serious about health. Passionate about care.
3.2 Complaints:
In addition to providing all patients with an opportunity to complete a satisfaction survey
BMI The Clementine Churchill 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:
Stage 3:
Corporate resolution
Patient can ref their complaint to independent adjudication if they are not
satisfied with the outcome at the other 2 stages
The majority of complaints are financial, in particular around transparency of fees which we
are continually looking at ways to improve through signage and patient information. Other
complaint themes are around dissatisfaction with clinical outcome, or clinical care received.
All complaints are responded to within 20 working days, and complaints are discussed daily
at morning Managers Ops meeting, with weekly totals and learns from complaints
discussed and displayed in all areas.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
13
BMI Healthcare
Serious about health. Passionate about care.
4. CQUINS:
The Clementine Churchill Hospital took part in CQUINs for North West London, the Friends
and Family test, the Safety Thermometer focusing on falls, and Alcohol Intervention, Follow
up DNA rates and Discharge Summaries to GPs were monitored in FY14-15 , with additional
audits on Smoking Cessation, Nutritional Assessments and WHO checklist carried out for
London. Four out of five of CQUINs were achieved last year.
5. NATIONAL CLINICAL AUDITS:
The Clementine Churchill 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. This information is not available.
6. RESEARCH:
No NHS patients were recruited to take part in research.
7. PRIORITIES FOR SERVICE IMPROVEMENT:
1. To develop and improve colorectal service, linking in with St Marks and our consultants
to develop the colorectal care delivered at Clementine Churchill Hospital, with the
support from out ITU for the complex cases.
2. To increase orthopeadic capacity for Hip, Knee and Shoulder procedures, and ensure all
patients where clinically appropriate follow the ERP pathway for all joint replacement
surgery.
3. Utilise the new endoscopy unit opening June 2015 to support local 2 week diagnostic
pathways, and the development of our colorectal service.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
14
BMI Healthcare
Serious about health. Passionate about care.
8. MANDATORY QUALITY INDICATORS:
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for
the Clementine Churchill Hospital for the reporting period.
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0.2288
April 2014-March 2015
0.9987
1.1849
0.58345
This value represents the rate of mortalities at the hospital in the reporting period. This was
below the lowest national score. All mortalities were non-perioperative, with only one
unexpected.
8.2 The Clementine Churchill Hospital patient reported outcome measures scores for
(i) Groin hernia surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
April 14 – Sept 14
0.0786
0.278
-0.112
There were minimum numbers going through the process for groin surgery so the
Clementine Churchill Hospital was unable to be scored on this element.
The Clementine Churchill Hospital intends to take the following actions to improve this
score, and therefore the quality of service by promoting completion of the PROMS with
every patient.
(ii) Varicose vein surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
April 14 – Sept 14
-7.395
-1.957
-12.571
No data was provided for varicose veins.
(iii) Hip replacement surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
Apr 14 – Sept 14
21.542
28.6
9.714
(iv) Knee replacement surgery:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
NA
Apr 14 – Sept 14
16.641
24.429
5.833
As with groin surgery above there were minimum numbers going through the process for
hip and knee replacement surgery so the Clementine Churchill Hospital was unable to be
scored on this element. Actions are as with groin surgery.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
15
BMI Healthcare
Serious about health. Passionate about care.
8.3 (i) The percentage of patients aged 0-14 readmitted to the hospital within 28 days of
being discharged:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0%
Apr 11 – Mar 12
11.45
14.35
7.96
(ii) The percentage of patients aged 15 or over readmitted to the hospital within 28
days of being discharged:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0.4%
Apr 11 – Mar 12
10.01
14.51
5.54
The percentages for BMI Clementine Churchill Hospital are well below the national
average. Re-admission rates continue to be monitored on a monthly basis to observe for
trends.
8.4 The BMI Clementine Churchill’s responsiveness to the personal needs of its patients
during the reporting period:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
90.99%
2013-2014
68.7
85
54.4
This figure again exceeds the highest national score. Responsiveness continues to be
monitored on a monthly basis through patient satisfaction data, monitoring of patient
satisfaction action plans at monthly meetings, and daily patient visits enabling immediate
action to rectify any issues raised.
8.5 The percentage of patients who were admitted to BMI Clementine Churchill Hospital
and who were risk assessed for venous thromboembolism (VTE) during the
reporting period:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
98.99%
April 2014 – Jan 2015
95
100
87
This score is above the national average and is an improvement upon last year’s score of
97%. This is down to a focus on VTE risk assessment through monthly audits.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
16
BMI Healthcare
Serious about health. Passionate about care.
8.6 The rate per 100,000 bed cases of C difficile infection reported within The BMI
Clementine Churchill Hospital amongst patients aged 2 or over during the reporting
period:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0
April 2013 – March 2014
14.7
37.1
0
Again this meets the lowest national score and will continue to be maintained through strict
adherence to infection prevention and control practices, policies, surveillance and audits,
and working closely with our Consultant Microbiologist.
8.7 The number and rate of patient safety incidents reported within The BMI Clementine
Churchill Hospital during the reporting period:
Number of patient safety incidents reported:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
640*
Oct 13- Sep 14
20
139
0
Rate of patient safety incidents reported (per 100 bed days):
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
3.7236*
Oct 13- Sep 14
3.589
7.496
0.0245
Number of patient safety incidents that resulted in severe harm or death:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0*
Oct 13- Sep 14
40.2
97
0
Percentage of patient safety that resulted in severe harm or death (per 100
admissions):
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
0%*
Oct 13- Sep 14
0.3
2.4
0
*Figures given for BMI Clementine Churchill Hospital are for the period of April 2014 –
March 2015 which would explain the high numbers of incidents, although it can be seen
that the rate is similar to the national average. The hospital has a healthy incident reporting
and incident feedback culture with incidents being monitored on a daily basis.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
17
BMI Healthcare
Serious about health. Passionate about care.
8.8 The percentage of staff employed by BMI Clementine Churchill Hospital who would
recommend the hospital as a provider of care to their family or friends:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
2014
64.58
96.43
33.73
There are no figures available for staff recommendations.
9. NON MANDATORY QUALITY INDICATORS:
9.1 The percentage of those who received care as inpatients or discharged from A&E
who would recommend BMI Clementine Churchill Hospital as a provider of care to
their family or friends:
Unit
Reporting Periods
(at least last 2)
National
Average
Highest National
Score
Lowest National
Score
73.42%
Jun 13 – Jan 14
66.23
94.38
35.63
This response rate is above the national average. We are focusing on this quality indicator
by completing daily patient visits in which a member of the management team obtains
feedback regarding the patient experience including the friends and family question and
linking into the Chief Nurse of England 6C’s.
BMI Clementine Churchill Hospital Quality Accounts 2014 - 2015
18