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 BMI The Edgbaston Hospital BMI The Edgbaston hospital is part of BMI Healthcare, Britain's leading provider of independent healthcare with a nationwide network of hospitals & clinics performing more complex surgery than any other private healthcare provider in the country. Our commitment is to quality and value, providing facilities for advanced surgical procedures together with friendly, professional care. BMI The Edgbaston Hospital has 50 beds with all rooms offering the privacy and comfort of ensuite facilities, Freeview TV and telephone. The hospital has three Laminar-flow theatres and a minor operations/endoscopy suite. The modern and spacious endoscopy/minor operations suite serves patients with a wide range of endoscopic procedures, many of which will be carried out as a walk-in, walk-out service. The leading-edge suite is fitted with the very latest in endoscopic technology and this enables top quality high-definition images to be captured. These facilities, combined with the latest in technology and on-site support services, enable our consultants to undertake a wide range of procedures from routine investigations to surgery. This specialist expertise is supported by caring and professional medical staff, with dedicated nursing teams and Resident Medical Officers on duty 24 hours a day, providing care within a friendly and comfortable environment. The Edgbaston Hospital offers the following:• • • Access to all elective specialties from Orthopaedics to Dermatology Dedicated ENT treatment room Audiology • • • • • • • Endoscopy + Minor Operations Suite Choose & Book Clinics offering patient choice to NHS Patients Physiotherapy Plain X-ray/Ultrasound Mobile MRI Cosmetic Surgery Chiropody + Podiatry Edgbaston Hospital works closely with supporting local NHS Trusts and offers Patient Choice for selected clinics via Choose and Book, NHS works equates to 56.5% of the overall work . Choose and book clinics offered to NHS patients include Gastroenterology, Hip, Knee, Hernia, Urology, ENT(nose) and Gynecology clinics to name but a few. BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the Health & Social Care Act 2008. BMI Edgbaston Hospital is registered as a location for the following regulated services:• • • Treatment of disease, disorder and injury Surgical procedures Diagnostic and screening The CQC carried out an unannounced inspection on 6th February 2014 and found that we met all standards. 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 The Edgbaston Hospital has a local framework through which clinical effectiveness, clinical incidents and clinical quality is monitored and analysed. Where appropriate, action is taken to continuously improve the quality of care. This is through the work of a multidisciplinary group and the Medical Advisory Committee. Regional Clinical Quality Assurance Groups monitor and analyse trends and ensure that the quality improvements are operationalised. At corporate level the Clinical Governance Board has an overview and provides the strategic leadership for corporate learning and quality improvement. There has been ongoing focus on robust reporting of all incidents, near misses and outcomes. Data quality has been improved by ongoing training and database improvements. New reporting modules have increased the speed at which reports are available and the range of fields for analysis. This ensures the availability of information for effective clinical governance with implementation of appropriate actions to prevent recurrences in order to improve quality and safety for patients, visitors and staff. At present we provide full, standardised information to the NHS, including coding of procedures, diagnoses and co-morbidities and PROMs for NHS patients.There are additional external reporting requirements for CQC, Public Health England (Previously HPA) CCGs and Insurers 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 l 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 for The Edgbaston Hospital. We have had: • 0 MRSA bacteraemia cases/100,000 bed days • 0 MSSA bacteraemia cases /100,000 bed days • 0 E.coli bacteraemia cases/ 100,000 bed days • 0 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. Our rates of infection are; • • 0% for hips 0% for knees Infection Prevention & Control (IPC) environmental and clinical audits are carried out within all departments of the hospital in accordance with the BMI IPC annual programme. The environmental audits are performed using the Infection Prevention Society (IPS) quality improvement tool (QIT). QIT audit results are reviewed by the IPC team and areas of concern are re-visited at more regular intervals with action plans being devised for desired improvements. Challenges presented by the general hospital environment throughout the QIT audits are addressed by our Hospital refresh program, which is a schedule of minor Hospital improvement works. Edgbaston do very well on the PVD and CVC audits scoring 100%. In areas where we fall short with a result of less than 90% these have been recorded and reported to the Heads of Departments and an action plan is instigated to improve matters which is discussed at the hospital Infection Control meetings. All clinical staff at Edgbaston are enrolled in a programme to achieve full competency in aseptic Non-touch technique (ANTT). This is a cascading programme where the IPCLP will train the staff in their area on ANTT. 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 Edgbaston Hospital PLACE assessment involved 40% patient assessors. The IPC, catering and housekeeping teams work closely together to fulfil the requirements of the PLACE audit on an annual basis and the results will show how hospitals are performing nationally and locally. In the last available PLACE audit, BMI The Edgbaston Hospital scored ‘Good’ for environment, food, privacy and dignity. Areas to consider for improvement following the PLACE Assessment included displaying cleaning schedules in the patient areas and some external paintwork requiring attention both of which are being addressed 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 Edgbaston 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 100% compliance. We aim to maintain this result by ensuring that all staff attend training for VTE Risk assessments and are aware that all patients require this assessment. All new starters at the hospital also receive this training. BMI Edgbaston 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. At BMI Edgbaston Hospital one orthopaedic consultant scans all joint replacement patients for deep veined thrombosis even if asymptomatic and this results in slightly higher detection rates. 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 The Edgbaston Hospital. As there were less than 30 cases for knee replacement during the reporting period, there is no data available for reporting at this time. BMI Edgbaston will continue to strive to ensure all questionnaires are completed for patients undergoing a hip or knee replacement in order to achieve compliance. Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved. Oxford Hip Score average April 14 – September 14 Q1 Q2 The Edgbaston Hospital 22.444 43.222 Health gain periods 20.778 England 18.16 40.081 21.922 between reporting between reporting Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved. Oxford Knee Score average April 14 – September 14 The Edgbaston Hospital No data No data Health gain periods No data England 19.401 16.702 Q1 Q2 36.103 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 Local progress as follows; • • • Patient education and information on carbohydrate loading is in place. One stop pre-assessment clinics to allow patients access Introduction of telephone pre assessments for minor surgeries or where patients are unable to attend • Multi disciplinary Joint schools are in place offering support for groups of patients undergoing joint surgery pre and post operatively. To assist patient setting their own goals • Patient education at pre assessment regarding the proposed patient’s pathway to allow patients and their families to plan their discharge Multidisciplinary Team working with patients to aid early discharge inc OT, physiotherapy, pharmacy, nurses Post discharge phone calls to all patients to allow patient continuity on leaving the hospital 2.3 Unplanned Readmissions within 31 days and unplanned returns to theatre. This data is tracked monthly and scrutinized by the Director of Nursing to look for trends or any concerns. The data is fed back through the Integrated Governance Committee and Medical Advisory Committee. Unplanned re-admissions are usually as a result of a clinical complication related to the original surgery. All unplanned returns to theatre are looked at in detail to ensure there are no clinical concerns. 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. Over the reporting period, BMI The Edgbaston Hospital scored over 97% for Impression of Admission, Impression of Consultant, Impression of Accomodation and Average Impression of Quality of Care. Patient’s Impression of Catering has been scored at 91% - actions are in place to improve this service and improve the impression of catering for patients: • Within the ward area protected meal times have been implemented in order that patients are not disturbed during meal times. • • • Introduction of the chef visiting inpatients on a daily basis to discuss options offered for that day and any alternative menus that are available. Temperature of food has also been a focus following review of catering services and this has now been actioned by staff ensuring meals are hot when served to patients. Impression of discharge has also been reviewed to ensure patients are discharged within a timeframe whenever possible. Staff ensure that all documentation and medication is prepared for patients in order that delays are minimised prior to discharge. NHS data for satisfaction over the last year, and latest patient satisfaction figures (analysis by funding type) for April 2015 are shown below: 3.2 Complaints In addition to providing all patients with an opportunity to complete a satisfaction survey BMI The Edgbaston 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. BMI The Edgbaston Hospital continues to have very low levels of complaints with less than 1 per 100 patients admitted. All complaints are dealt with promptly and closed appropriately. Trends are monitored and there has been a slight growth in complaints regarding communication issues. However, a proportion of these are in association with the private insured/self pay patients -with the focus on disagreements over fees or services rendered often resulting from issues raised in policy coverage and short falls. To assist in clarity of pricing information, BMI Healthcare publishes all associated pricing and advises patients of their liability within hospital signage and literature. It is however pleasing to report that complaints regarding hospital care delivery remains very low. The Edgbaston Hospital has taken the following actions to further lower complaint numbers and the quality of our services: • • Monthly debrief on all complaints at Clinical Governance and cascaded down through leads and departmental meetings to discuss outcomes and learnings within teams for reflection and improvement. Formation of new patient satisfaction group which reviews trends of patient satisfaction verbatim comments and complaints to feed back to relevant staff and communicates learnings. Action plans formed to implement any improvements needed. Consultant complaints are shared with consultants at the Medical Advisory Committee. They are held on Consultants practicing privileges files and all records are monitored for trends, with meetings held to address any concerns/ improvements in service as required. 4. CQUINS Performance against CQUIN for 14/15 Financial Year has been confirmed as full achievement by the lead commissioner. The increase in response to ‘Friends and Family’ is due to improving the hospital internal process for distribution and capture - which in turn has led to heightened awareness of the importance of patients completing these forms (to enable the hospital to review results and utilize patient comments in order to facilitate positive changes.) Indicator Actual Level CQUIN Achievement Friends and Family Early Implementation of FFT - show implementation by Completed October 2014 to daycase and outpatients. 100% Increased or maintained response rate, Q1 20% and Q4 45% at Q4 25% 100% NEW Scoring Real time audit of NEWS scoring (National Early Warning 100% Score) for all patients with a stay greater than 24 hours 100% Vascular Access Care Bundle Reduce complications associated with the use of peripheral 100% vascular access device. 100% 5. National Clinical Audits The Edgbaston 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. Please see the NJR Reports website at www.njrreports.org.uk. 6. Research No NHS patients were recruited to take part in research. 7. Priorities for service development and improvement • • • • Appointment and retention of high quality clinical and non-clinical staff in order to reduce agency usage. Ongoing engagement with NHS Commissioners to enhance patient choice and service delivery to NHS patients. Promote and educate staff to achieve positive responses for patient satisfaction. Development of the Walk in walk out facility to further develop this service to meet the needs of the changing patient requirements. 8. Mandatory Quality Indicators 8.1 The value of the summary hospital-level mortality indicator (SHMI) for the The Edgbaston Hospital for the reporting period. Unit 0 Reporting Periods National (at least last two Average reporting periods) Oct 2012 – Jun 2014 0.9987 Highest Score National Lowest Score 1.1849 National 0.58345 The BMI Edgbaston Hospital considers that this data is as described. 8.2 The Edgbaston Hospital’s patient reported outcome measures scores for (i) Groin hernia surgery Unit No data Reporting Periods National (at least last two Average reporting periods) Apr 14 – Sept 14 0.0786 Highest Score 0.278 National Lowest Score National -0.112 The Edgbaston Hospital has undertaken less than 30 cases in the reporting period and as such, no score has been given. (ii) Varicose vein surgery Unit N/A Reporting Periods National (at least last two Average reporting periods) Apr 14 – Sept 14 -7.395 Highest Score -1.957 National Lowest Score National -12.571 The Edgbaston Hospital does not undertake Varicose Vein surgery via NHS route, and as such, no data is available. (iii) Hip replacement surgery Unit Reporting Periods National (at least last two Average reporting periods) Highest Score National Lowest Score National 22.444 Apr 14 – Sept 14 21.542 28.6 9.714 The Edgbaston Hospital considers that this data is as described. The Edgbaston Hospital has taken the following actions to improve this score, and so the quality of its services, by advising patients that moderate activity is beneficial and is important that they continue to undertake all activities of daily living and instructing patients that it is important that they continue with physiotherapy following surgery to enhance their recovery. (iv) Knee replacement surgery during the reporting period. Unit No score Reporting Periods National (at least last two Average reporting periods) Apr 14 – Sept 14 16.641 Highest Score National Lowest Score 24.429 National 5.833 The Edgbaston Hospital has only undertaken a small amount of knee replacement cases in the reporting period and as such, no score has been given. 8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of The Edgbaston Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Unit N/A Reporting Periods National (at least last two Average reporting periods) Apr 11 - Mar 12 11.45 Highest Score National Lowest Score 14.35 National 7.96 The BMI Edgbaston Hospital does not admit paediatric patients for surgery. 8.3(ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of The Edgbaston Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Unit 0.0627% Reporting Periods National (at least last two Average reporting periods) Apr 11 – Mar 12 10.01 Highest Score 14.51 National Lowest Score National 5.54 The Edgbaston Hospital considers that this data is as described. It is noted that this is a very low percentage - however, The Edgbaston Hospital intends to continue to investigate contributing factors to readmission in order to reduce recurrent incidents. 8.4 The Edgbaston Hospital’s responsiveness to the personal needs of its patients during the reporting period. Unit 97.02% Reporting Periods National (at least last two Average reporting periods) 2013-2014 68.7 Highest Score 85 National Lowest Score National 54.4 The Edgbaston Hospital considers that this data is as described. The Edgbaston Hospital has taken the following actions to improve this percentage and the quality of its services: Continuing to monitor all patient feedback through patient satisfaction questionnaires that are given to all patients following their stay/procedures in both an inpatient and outpatient setting. These results are then discussed at Patient Satisfaction Group meetings with both clinical and non-clinical staff. Actions are then put in place to improve all aspects of patient’s quality of care. 8.5 The percentage of patients who were admitted to The Edgbaston Hospital and who were risk assessed for venous thromboembolism during the reporting period. Unit 100% Reporting Periods National (at least last two Average reporting periods) Apr 14 – Jan 15 95 Highest Score 100 National Lowest Score National 87 The Edgbaston Hospital considers that this data is as described. BMI The Edgbaston Hospital can confirm that NHS patient records are audited and VTE is confirmed as having been undertaken at pre-assessment and reviewed every 24 hours. 8.6 The rate per 100,000 bed days of cases of C difficile infection reported within The Edgbaston Hospital amongst patients aged 2 or over during the reporting period. Unit 0 Reporting Periods National (at least last two Average reporting periods) Apr 13 – Mar 14 14.7 Highest Score 37.1 National Lowest Score National 0 The Edgbaston Hospital considers that this data is as described. There have been no cases of C difficile infection during the reporting periods. 8.7 The number and, where available, rate of patient safety incidents reported within The Edgbaston 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 411 Reporting Periods National (at least last two Average reporting periods) Oct 13 – Sep 14 20 Highest Score National Lowest Score 139 National 0 Rate of patient safety incidents reported (Incidents per 100 Bed Days) Unit 12.1085 Reporting Periods National (at least last two Average reporting periods) Oct 13 – Sep 14 3.589 Highest Score National Lowest Score 7.496 National 0.0245 Number of patient safety incidents that resulted in severe harm or death Unit 0 Reporting Periods (at least last reporting periods) Oct 13 – Sept 14 National two Average 40.2 Highest Score 97 National Lowest Score National 0 Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100 Admissions) Unit 0.00% Reporting Periods (at least last reporting periods) Oct 13 – Sept 14 National two Average 0.3 Highest Score 2.4 National Lowest Score National 0.0 The Edgbaston Hospital considers that this data is as described, however it is noted that although the number of patient safety incidents reported is much higher than the national average – The Edgbaston Hospital feels this is due to a robust reporting structure, and a high proportion of day case to overnight stays recorded (which are closely monitored for trends – the highest proportion being due to the time of day of surgery). The Edgbaston Hospital has taken the following actions to improve this rate and the quality of its services: Review undertaken of the protocols for the clinical staff to refer to when a patient’s condition is deteriorating following surgery and implementation of the ‘SBAR’ assessment tool (within clinical areas) to monitor significant changes in a patient’s condition. 8.8 The percentage of staff employed by the Edgbaston Hospital during the reporting period, who would recommend the Edgbaston Hospital as a provider of care to their family or friends. Unit 96% Reporting Periods (at least last reporting periods) 2014 National two Average 64.58 Highest Score 96.43 National Lowest Score National 33.73 The Edgbaston Hospital considers that this data is as described. 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 Edgbaston Hospital as a provider of care to their family or friends. Unit 84.17% Reporting Periods (at least last reporting periods) Jun 13 – Jan 14 National two Average 66.23 Highest Score 94.38 National Lowest Score National 35.63 The Edgbaston Hospital considers that this data is as described. The Edgbaston Hospital has taken the following actions to improve this percentage and so the quality of its services: Close monitoring of patient satisfaction feedback through Patient Satisfaction Meeting with the Director of Nursing and key departmental representatives. Actions then implemented as required and reviewed at each meeting.