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 Coombe Wing is a 22-bedded unit within Kingston Foundation Trust NHS Hospital,
which offers a wide range of inpatient and outpatient services. We also provide care for
cancer patients including chemotherapy and palliative care. Our private maternity care
includes antenatal care, private delivery and post natal care.
Patients can access the services of BMI Coombe Wing by a referral from their general
practitioner to one of our consultants. In addition, patients can inform staff they would
like to use the private facilities if they are admitted in an emergency via the Accident &
Emergency department or onto a ward. We operate an urgent admission service for
general practitioners, which all local GP’s are aware of.
BMI Coombe Wing is available to anyone who wishes to pay for their healthcare
privately either through personal or company medical insurance, or by self-funding. We
have a fixed cost surgery scheme which has been designed for people who do not have
private medical insurance and offer all-inclusive packages for a wide range of surgical
procedures.
BMI Coombe wing is part of BMI Healthcare, Britain's leading provider of independent
healthcare across the UK. Our commitment is to quality and value, providing facilities for
advanced surgical procedures together with friendly, professional care.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC)
under the Health & Social Care Act 2008. BMI Coombe Wing is registered as a location
for the following regulated services:•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening procedures
The CQC carried out an unannounced inspection on 28th January 2014 and found the
unit to be fully compliant in the 8 standards that were reviewed. No actions were
required.
Respecting and involving people who use services
Met this standard
Care and welfare of people who use services
Met this standard
Meeting nutritional needs
Met this standard
Safeguarding people who use services from abuse
Met this standard
Cleanliness and infection control
Met this standard
Management of medicines
Met this standard
Supporting workers
Met this standard
Assessing and monitoring the quality of service provision
Met this standard
BMI Coombe Wing 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 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.
There are external reporting requirements for CQC, Public Health England (Previously
HPA) CCGs and Insurers. There has also been ongoing progress on the project to
collect and publish comparative data to assist patients and referrers with their choices
on healthcare facility. This has started with the launch of an independent Private
Healthcare Information Network website http://www.phin.org.uk This provides
information on facilities, numbers of a variety of procedures carried out at each site and
some basic quality indicators. The range of the available indicators will continue to grow
for ongoing enhancement of choice.
1. Safety
1.1 Infection prevention and control
The focus on infection prevention and control continues
under the leadership of Corporate Head of Infection
Prevention and Control and in liaison with the infection
control nurses in Kingston Hospital NHS Foundation Trust.
We have had: • No cases of MRSA bacteraemia in the last year
(NHS 1.17cases/100,000 bed days).
• Two cases of Clostridium difficile in the last 12 months. The source of which is
unknown.
Coombe Wing’s infection prevention and control lead nurse has worked closely with the
clinical team to ensure they adhere to the ‘bare below the elbow’ policy and to improve
hand hygiene compliance through audit and education. She has taught ANTT (aseptic
non-touch technique) to all of the registered nurses and assessed their competency.
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)
BMI Coombe wing conduct our annual PLACE assessment in conjunction with Kingston
Hospital NHS Foundation Trust.
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 (Patient led assessment of the care
environment) assessments provide motivation for improvement by providing a clear message,
directly from patients, about how the environment or services might be enhanced.
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.
In 2014 BMI Coombe Wing achieved the following results:
Cleanliness
Food
Overall
Ward
Food
Organisation
Food
Privacy,
Dignity
and
Wellbeing
Condition
Appearance
and
Maintenance
100%
97.21%
98.15%
96.09%
91.67%
89.19%
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 Coombe Wing. 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 improvements in the completion of a VTE
assessment on admission and the appropriate pharmaceutical prophylaxis prescribed as
required and/or the use of mechanical prophylaxis if indicated. Action plans have included
emphasis of importance of assessment on admission and follow up at 24 hours and 7 days. The
Nurse in Charge checks daily that all assessments have been completed.
BMI Coombe Wing 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. .
BMI Coombe Wing has no reported cases of DVT or Pulmonary embolism for 2014/ 2015.
2. Effectiveness
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
BMI Coombe Wing works closely with Kingston Hospital NHS Foundation Trust to provide
ERP’s to relevant patients. Our average length of stay for all patients has remained static for the
last three years.
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.
Patients readmitted through choice, choose BMI Coombe Wing as they feel confident in the
clinical care.
BMI Coombe Wing is situated within an acute NHS Trust and is able to provide acute care to
complex surgical patients with the assurance of intensive care facilities close at hand.
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.
97.1& of BMI coombe Wing patients in 2014 said the quality of their care was very good or
excellent.
BMI Coombe Wing have an average impression of admission is 92%. Average impression
the consultant is 99.1%, average impression of nursing is 98.3%, average impression
accomodation is 86.5%, average impression of catering is 82.4%, average impression
discharge is 89.7%, average impression of quality of care is 97.1%, likelyhood
recommendation to family & friends is 100%.
We are working hard on improving our response rate to completing questionnaires.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Coombe Wing 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.
of
of
of
of
BMI Coombe Wing has seen an increase in complaints with no specific trend. All complaints
were answered in full with appropriate action plans in place.
4. Priorities for service development and improvement
Maternity
Private maternity care is increasing year on year at BMI Coombe Wing. We are pleased to now
offer antenatal classes and post natal home visits.
Improving the patient experience
BMI Coombe wing is situated within Esher Wing of Kingston Hospital. The Trust are in the
process of replacing the windows from single glazed to double glazed. This will improve the
temperature control of Coombe which struggles in the heat in the summer and the cold in the
winter.
The Trust have replaced the pipe work in the building and this has improved the water flow in
our showers and basins.
Coombe have worked closely with the ophthalmic consultants to run clinics within their
departments with BMI reception staff. There are now two busy clinics running per week in the
evenings.
We have increased our bookable theatre sessions by 35% and continue to work closely with the
Trust to improve theatre access for our consultants.
8. Mandatory Quality Indicators:
The reporting of incidents is key to working towards solutions to reduce such incidents in the
future. The learning that takes place during an investigation enables action plans to be drawn up
in order to improve. The increase in incidents is due to our improved reporting mechanisms
where we actively encourage staff to report all incidents including near misses. An increase in
activity leads to a increase of reported incidents/ complaints.
BMI Coombe Wing staff work closely with our doctors to ensure our patients feel confident &
comfortable with the clinical care they receive.
All patients are nurses in single rooms with onsuite facilities.
Our staff are respectful of our patients privacy and are focused on individual needs.
During 2014 our discharge process improved with introduction of improved discharge packs,
provision of up dated discharge leaflets and advice tailored to specific patient conditions. Follow
up phone call have been well received by our patients when they are at home.