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 Fernbrae Hospital is located in the west end of Dundee, in one of the city’s conservation
areas. A partially listed building, it has an enviable view over the River Tay and the banks of
north-east Fife. The hospital serves the people of Tayside, Angus, Perthshire and Fife, is easily
accessible by local bus services or car and parking is available at the front and rear of the
building.
The building has been a health care establishment for over 90 years and is now part of BMI
Healthcare, the largest independent healthcare provider in the UK.
A wide range of surgical procedures are carried out from routine investigations to complex
surgery including major joint replacements. Over 100 consultants have Practicing Privileges
and they receive support from a Resident Medical Officer.
The hospital has 15 en-suite patient bedrooms which are fitted with a remote controlled flat
screen television and telephone facility. We have recently had Wi-Fi installed into each ward
area which serves each patient bedroom and we plan to extend this facility in the future months
to help enhance consultant services.
The hospital has one operating theatre with laminar airflow to assist in the prevention of
infection.
In addition the hospital also offers the following•
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Outpatient Service
Bariatric Service
Cardiology Service
Clinical Psychology Service
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Cosmetic Service
Dermatology Service
Ear, Nose & Throat Service
Endoscopy Service
Health Screening Service
Pharmacy Service
Physiotherapy Service including Complementary Therapy and Hand Therapy
Radiology Service including MRI
Ophthalmology
Outpatient Fertility Service
The hospital’s endoscopy examination room and decontamination areas were upgraded in 2013
to a very high standard including the installation of a new Endoscopy Washer/Disinfector for the
disinfection of endoscopes.
We also use a specialized piece of equipment for the initial decontamination of our endoscopes
to ensure a high standard of cleanliness prior to further washing and disinfection.
The hospital’s mission statement “To be Tayside’s Independent Healthcare Provider of first
choice, positively contributing to the health of the community we serve” encompasses the very
positive motivation of the team at BMI Fernbrae Hospital.
All the staff at BMI Fernbrae Hospital are committed to ensuring that you are confident and
comfortable with every aspect of your visit. Our Director of Clinical Services is available to
address any concerns you may have and there is a Resident Medical Officer available 24 hours
a day.
NHS Activity
BMI Fernbrae Hospital are currently involved in carrying out a very small number of NHS
procedures.
Healthcare Improvement Scotland (HIS)
BMI Healthcare, Fernbrae Hospital are registered as a provider with Healthcare Improvement
Scotland (HIS) under the Health & Social Care Act 2008. BMI Fernbrae Hospital is registered as
a location for the range of services described above.
HIS carried out an unannounced inspection on 25th June 2014 and measured outcomes related
to the following themes •
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Quality of Information
Quality of Care & Support
Quality of Environment
Quality of Staffing
Quality of Care Staff
Quality of Management and Leadership
All recommendations related to the above themes have been actioned and implemented,
leading to an increased level of quality patient care.
The Healthcare Associated Infection Standards have been reviewed and published by HIS (Feb
2015) and BMI Fernbrae are currently working with these to assist with the quality of patient
centered care expected from the standards.
BMI Fernbrae 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 the multidisciplinary group
and the Medical Advisory Committee (MAC).
A Regional Quality Assurance Board monitors and analyses trends and ensure that the quality
improvements are operationalised.
At corporate level the Quality Assurance Board has an overview and provides the strategic
leadership for corporate learning and quality improvement. There is an appropriate structure of
reporting and escalation in place to enhance the effectiveness of this group, with a robust
governance structure for the Prevention and Control of Infection.
There is an 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 Fernbrae Hospital are currently undergoing an ongoing programme of refurbishment which
will continue throughout 2015 and includes the following upgrades and replacements •
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New Handwashing sinks throughout (Compliant with Scottish Infection Prevention and
Control Regulation)
En-suite wetroom facilities in patient bedrooms
Development of improved nursing preparation rooms
Replacement of nursing station in Strathtay ward
Replacement of medical and nursing equipment in all clinical areas including ward,
theatre and Out-patient departments
Replacement of areas of external boundary wall to enhance the hospital grounds
Installation of a new and upgraded fire alarm system for the improvement of health and
safety of staff and patients
BMI Fernbrae Hospital’s clinical team liaise with the local NHS trust specialists, Scottish
National Blood Transfusion Service (SNBTS) groups in relation to the transfusion, recording and
traceability of blood and blood products and also with the trust specialists for Infection
Prevention and Control where appropriate.
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 Infection Prevention and Control
Lead nurse in BMI Fernbrae Hospital.
BMI Fernbrae Hospital have an excellent record of Infection
prevention and Control and have had: • Zero cases of MRSA bacteraemia in the last 12 months
• Zero cases of MSSA bacteraemia in the past 12 months
• Zero cases of E.coli bacteraemia in the past 12 months
• Zero cases of hospital apportioned Clostridium Difficile
in the last 12 months.
BMI Fernbrae Hospital have an annual programme of Infection Prevention and Control audits
which cover each department in the hospital. Where appropriate, action plans are completed
with follow-up review to ensure all actions are implemented. The audits are as follows •
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Departmental hand hygiene audit
Annual departmental environmental audit
High impact care bundles (Intravenous cannulation and hand hygiene to be implemented
in May 2015)
Patient mattress audits in ward, theatre and imaging departments
Standards of Housekeeping audits carried out on a monthly basis
BMI Fernbrae Hospital participate in a company wide mandatory staff training programme
directly related to Infection Prevention and Control including the following elements –
Aseptic Non-Touch Technique (ANTT) training was carried out in the hospital over 2014-2015
and 100% of our Registered Nurses completed this. All new staff carry out this training as part
of their induction process.
Hand hygiene practical training which is scheduled to commence in May for 2015 and is being
carried out by an external company and an Infection prevention and Control Lead Nurse.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
1.2 Venous Thrombo-embolism (VTE)
BMI Healthcare, holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including, BMI Fernbrae 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 that BMI Fernbrae Hospital are 100%
compliant with the requirements.
BMI Fernbrae 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. . BMI Fernbrae Hospital had no incidence of VTE in the period 1st April 2014 to 31st
March 2015.
2. Effectiveness
2.1 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 relatively 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. The average length of stay in hospital for patients receiving hip or knee
replacement surgery at BMI Fernbrae during the period 1st April 2014 to 31st March 2015 was as
follows –
Hip Replacement Surgery
3.2 days
Knee replacement surgery
3.8 days
The numbers of the above procedures carried out at BMI Fernbrae during the same period were
as follows –
Hip replacement surgery
18
Knee replacement surgery
9
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 Fernbrae Hospital have had a successful and significant reduction in patient length of
recovery/hospital stay with improved benefits for patients in relation to rapid recovery with
increased activity in the first two post operative days and will continue to treat patients using the
ERP pathway.
2.2 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. BMI Fernbrae have a low incidence of unplanned
returns to theatre which is very likely a result of a robust pre-admission assessment process for
appropriate patients.
BMI Fernbrae Hospital had 2 unplanned readmissions within 31days of discharge and 1
unplanned returns to theatre from 1st April 2014 to 31st March 2015. There are theatre staff
available on an on-call system 24hrs a day to provide access to theatre and prompt treatment.
There were 2 unplanned transfers to Local NHS Trust Hospital during the above period both
due to complications related to the original surgery. Please see graph below showing
unplanned transfers to NHS facilities.
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.
The questionnaire also asks how the patients rated their overall quality of care (which takes into
account all areas of their care and treatment as outlined below). This is measured across two
catagories, very good and excellent. The graphs below compare the years 2013/14 from 1st
April to 31st March and the same time period for 2014/15.
During the period 1st April 2013 to 31st March 2014 BMI Fernbrae Hospital received 680
completed patient questionnaires.
During the period 1st April 2014 to 31st March 2015 BMI Fernbrae Hospital received 540
completed patient questionnaires.
All our staff are dedicated to providing the best possible patient care and patients are
particularly appreciative of their efforts. We are pleased to report that 100% of our patients
rated their Overall Quality of care as good, very good or excellent.
On other key issues the patient ratings for BMI Fernbrae Hospital were as follows –
(all % good, verygood or excellent):
Overall impression of the arrival process
Overall impression of nursing care
Consultant surgeon/physician
Diagnostic imaging (X-Ray)
Physiotherapy
Pharmacy
93.8%
97.2%
100%
100%
96.4%
97.2%
Consultant anaesthetist
Theatre staff
Accomodation
Catering
Discharge procedure
100%
99.2%
92.3%
89.2%
95.2%
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Fernbrae 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.
Between 1st April 2014 and 31st March 2015 there were 17 written complaints received by the
hospital.
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Clinical
Non-Clinical (Patient Involved)
Non-Clinical (No Patient Involved)
2
8
7
We ensure that all patients are given the information via the “Please Tell Us” leaflet which
outlines the complaints procedure. The majority of the above complaints were in relation to
financial queries and were all resolved at hospital level. We have met face to face with the
complainants on three occasions during the period 1st April 2014 to 31st March 2015. We
ensure our complaints are readily available for Health Improvement Scotland (HIS) inspection
as required. We currently have no stage 2 or 3 complaints.
National Clinical Audits
BMI Fernbrae Hospital participates in a local audit with NHS Tayside for hip and knee
replacement surgery.
Research
No NHS patients were recruited to take part in research.
Priorities for service development and improvement
The following are some of our planned priorities during the year at 1st April 2015 to 31st March
2016 from a clinical perspective –
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Development of Fertility Clinic
Improvements in Average Length of Stay for patients receiving hip or knee replacement
procedures
Continual development an improvement in BMI Fernbrae Hospital audit programme to
assist with the maintenance of high quality care and services
Continue with our ongoing programme of GP educational events/evenings