BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
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
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
BMI Goring Hall Hospital has 23 private inpatient rooms, all with en-suite bathrooms and a 4
bed High Dependency Unit. Day case patients are accommodated in a 12 bed surgical Day
Care Unit. In addition, the Day Care Unit can accommodate 8 ambulatory patients in recovery
chairs that facilitate early discharge. All accommodation is allocated to ensure that patients are
treated in a “same gender” area. Medical day care patients are treated in the Mulberry Suite,
which can accommodate 5 day care patients at any one time.
The hospital has a wide range of inpatient and outpatient services covering many specialties,
such as Orthopaedics, Gynaecology, Urology, Gastroenterology, General Surgery, General
Medicine, Cardiology, Pain Management, Ophthalmology and ENT.
Physiotherapy and rehabilitation services are managed by our specialist therapists.
The hospital benefits from a full range of diagnostic facilities including CT, MRI, Ultrasound,
Digital Mammography and X-ray.
The hospital treats patients with various funding routes, the majority of which are privately
funded. The hospital has successfully bid for NHS commission care delivery and in 2013/14
NHS cases accounted for 44% of total case load.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Goring Hall 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 7th January 2014 when five standards
were assessed. The hospital has demonstrated compliance to all these standards. Part of the
inspection involved inspectors that are specialists in their field meeting and talking to patients.
People who use BMI Goring Hall Hospital told the inspectors that their privacy and dignity was
respected. They said they had been given a lot of information before coming into the hospital.
This included a letter detailing the procedure and what was likely to happen. The letter also
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
included what would happen if things did not go according to plan. Patients stated that they felt
they were protected from the risk of abuse because the provider had taken reasonable steps to
identify the possibility of abuse and prevent abuse from happening. Patients praised the staff
and told us they were “knowledgeable”, “brilliant” and “very professional”. There were no
concerns raised about their attitude or competency.
BMI Goring Hall 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 multi-disciplinary group
and the Medical Advisory Committee.
Regional Clinical Quality Assurance Groups monitor and analyse trends and ensure that the
quality improvements are actioned. This forum is used to share learning across hospitals and
regions.
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 and 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, co-morbidities and PROMs for NHS patients.There are additional external reporting
requirements for CQC, Public Health England (Previously HPA) CCGs and Insurers.
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
BMI is a founder member of the Private Healthcare Information Network (PHIN) UK – where we
produce a data set of all patient episodes approaching HES-equivalency and submit this to
PHIN for publication. The data is made available to common standards for inclusion in
comparative metrics, and is published on the PHIN website http://www.phin.org.uk. This website
gives patients information to help them choose or find out more about an independent hospital,
including the ability to search by location and procedure.
1. Safety
1.1 Infection prevention and control
The focus on infection prevention and control continues under
the leadership of the Group Head of Infection Prevention and
Control, in liaison with the link nurse in BMI Goring Hall Hospital
We have had: • Zero MRSA bacteraemia cases/100,000 bed days
• Zero MSSA bacteraemia cases /100,000 bed days
• Zero E.coli bacteraemia cases/ 100,000 bed days
• Zero 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.
Environmental & practice audits are routinely completed in all clinical departments. This
enables the hospital to improve and continually monitor infection prevention controls. The
clinical teams also audit the service using nationally recognised tools from the Infection
Prevention Society (IPS).
The hospital promotes infection control incentives and standards through an Infection
Prevention and Control team. The team is led by a Director of Infection Prevention and Control
and supported by an ICP lead practitioner, who is responsible for ensuring that standards are
maintained throughout each hospital department. Each department has a designated ICP link.
The team audit practice and environment throughout the year according to an audit plan.
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
Department
Compliance
Actions
Radiology Environment
93%
New WC cleaning schedules displayed to public
Physiotherapy Environment
97%
Window replacement program
Oncology Environment
96%
Equipment cleaning regimen reviewed
Pharmacy Environment
98%
Minor paintworks
Theatre Suite Environment
91%
Endoscopy Decontamination
Compliant
Sharps Audit
91%
Team focused on correct labelling of sharps bins
Ilex ward- Hand Hygiene
100%
March 2015 demonstrated robust hand hygiene
practice of nursing teams
Theatre department repainted, worn equipment
replaced.
Following review by independent infection prevention
and control team -Minor environmental works have
been completed
These audits have highlighted areas for improvement:
Hand washing
Carpets in
clinical area
Interventional
room
A programme is in place to ensure that all clinical hand washing basins are compliant
with current guidelines.
All staff receive annual training on infection control
procedures.
Goring Hall Hospital has converted 57% of inpatient rooms to vinyl flooring. This
programme has been rolled out to the Outpatient setting where 93% of consulting
rooms have been refurbished and carpets removed. The remaining rooms will be
refurbished through a rolling programme.
The Consulting suite treatment room has been relocated and refurbished to provide an
environment that enhances infection control processes and provides a more
comfortable patient environment.
Clinical practice is monitored quarterly to ensure that practice standards based on high impact
interventions (Saving Lives Care Bundle) are consistently embedded in practice. These
research based practice standards are designed to reduce surgical site and peripheral line
infections. These standards are consistently applied in practice.
Pre-operative Interventions
Intra-operative Interventions
Intravenous cannula
interventions:
Post-operative interventions
MRSA screening, showering & hair removal
Skin preparation, prophylactic antibiotics, incises drapes,
supplementary oxygen, glucose control
Aseptic technique, hand hygiene, Skin preparation,
dressing
Hand hygiene, surgical dressing
100%
100%
100%
100%
Through these audits we have identified areas for improvement that are now consistently
applied:
•
•
The use of forced warm air for all patients having surgery for longer than 45 minutes.
The use of improved skin preparation for all surgery (unless patient has a sensitivity).
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April 2014 to March 2015
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly. The hospital monitors cleanliness through monthly
patient satisfaction feedback, departmental cleaning schedules and annual PLACE
assessments.
1.2 Patient Led Assessment of the Care Environment (PLACE)
We believe patients 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.
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April 2014 to March 2015
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 the patient’s privacy and dignity. Food, cleanliness and general building maintenance
are also assessed. The assessment focuses entirely on the care environment and does not
cover clinical care provision or how well staff are doing their job. It is carried out by previous
patients and results are validated by an independent assessor from Healthwatch.
The results will show how hospitals are performing nationally and locally. Results for 2014 are
as follows:
During 2015 the catering provision at BMI Goring Hall Hospital will change. This is part of a
national programme to standardize and improve catering provision throughout the group. This
programme will be monitored and reviewed, depending on the results of both PLACE
assessments and patient feedback.
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 Goring Hall Hospital. BMI Healthcare was awarded
the Best VTE Education Initiative Award category by Lifeblood in February 2013 and was the
Runner 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 assess every patient who is admitted to our facility
and the result of our audit has shown 100% compliance throughout the year. We intend to
maintain this position through continuous audit of compliance.
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
BMI Goring Hall 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, the hospital works with the local CCG to identify any
patients that are re-admitted to other hospitals to recognise VTE as a cause of this readmission.
Any identified cases of post-operative VTE are investigated and a root cause identified. The
learning from these investigations is discussed and shared through the Group Thrombosis
Committee. In 2014-15 there was one case of VTE representing a rate of 0.17 in a 1000
admissions. The national rate for VTE is 1 in a 1000 admissions.
In response to patient feedback BMI Goring Hall Hospital has changed the provision of
mechanical foot pumps to promote patient compliance during their inpatient admission.
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.
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
April 14 – September 14
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
Hospital
20.07
41.
20.9
England
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
BMI Goring Hall Hospital’s participation in PROMS remains high. All patients receive information
about the PROMS survey at their pre-assessment appointment. Pre-operative scores (Q1) are
dictated by local commissioners eligibility rules, that is that the Q1 score must be greater than
20 to be eligible for NHS funding. However health gain and health status are comparable with
national benchmarks.
April 14 – September 14
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
Hospital
21.25
35.125
13.8
England
19.401
36.103
16.702
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
Results for Knee replacements may be impacted by the age profile of the local population; West
Sussex has one of the most ageing populations in the UK. However, BMI Goring Hall Hospital
has instigated a project to identify knee replacement patients that have not achieved the
expected health gain at 3 months. Post-operative PROMS (Q2) surveys are conducted at 6
months. Therefore, once identified, further or additional therapy support can be instigated to
achieve an improved health gain. We envisage that improvements in these results will be
evident in 2015-16.
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
and 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
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April 2014 to March 2015
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
At BMI Goring Hall Hospital we have implemented an enhanced pre-assessment process. This
means that a proportion of pre-operative patients can be assessed and screened by a preassessment nurse on the day of their initial consultation with the surgeon. This will reduce that
number of hospital visits required and identify patient who require pre-operative optimisation
earlier in the pathway.
Average length of stay for hip and knee replacements is detailed below. The short length of
hospital stay is supported by advanced anaesthetic techniques, robust pathways and early
discharge planning. In some cases length of stay can be as short as 1 night for hip and knee
replacements.
LOS mean
Hip Replacements
3.4
Knee Replacements
2.4
Further advances in reducing length of stay and thereby reducing hospital associated acquired
complications have been achieved by following best practice principals for ambulatory care
pathways. The majority of operations performed at the hospital can be delivered safely through
a standardised 23 hours ambulatory care pathway. The day surgery unit has therefore been
expanded to accommodate the growth in ambulatory care procedures.
2.3 Unplanned Readmissions within 31 days and unplanned returns to theatre.
Unplanned readmissions are normally the result of a clinical complication related to the original
surgery. However, obtaining information from other hospitals about re-admissions can be
difficult. BMI Goring Hall Hospitals works in partnership with the Local CCG to identify any
readmission at any other hospital. Therefore, the hospital readmission data is more robust and
allows the clinical team to identify trends more easily.
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April 2014 to March 2015
Unplanned returns to theatre normally due to a clinical complication related to the original
surgery. BMI Goring Hall has implemented nationally recognised clinical tools that allow for
early recognition of deteriorating patients and rapid return to theatre as necessary.
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 hospitals performance is benchmarked against the whole group.
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
BMI Goring Hall Hospital has worked hard to improve the patient’s perception of the discharge
planning process. This has involved developing discharge pathways that start at the time of the
decision to treat. The results above demonstrate an improvement in the discharge planning
process.
Further improvements will continue in 2015-16:
• Relaunch a customer care training programme,
• reviewed catering provision,
• pharmacy assessment at pre-assessment and
• Involvement of patient in setting discharge goals.
• Develop pathways for pain management
• Support pain management through training
BMI Goring Hall Hospital obtains patient feedback from several other sources, i.e., Patient
Forums, commendations, complaints and structured patient interviews. The latter was focused
on understanding the pateint perception of what excellent care delivery looked like. Throughout
the year 30 patients a month were asked to take part in structured interviews. Patients were
asked to score actual care delivery against the Chief Nursing Officer’s 6 C’s, that describe what
good care should be. The results are illustrated below.
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April 2014 to March 2015
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Goring Hall 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 the hospital received 62 written complaints. All
complainants received a full response within 20 days from the Executive Director. Complaints
are reviewed at the bi-monthly Clinical Governance Committee where actions are confirmed.
Examples of action taken:
Catering
Admission times
Postponed surgery
Noise in HDU
Pre-assessment
Ophthalmology
Late running clinics
Introduced chef’s special to standard menu choices. Regular chef visits
to patients
Where possible admission times are arranged as close to the predicted
surgery time as possible
New date for surgery offered to patients prior to discharge following
postponed surgery
Nurse’s station redesigned to reduce noise disturbance
Clinic relocated to increase availability
Outpatient suite redesigned to reduce backlog in clinic.
Improved communication from theatre to ensure that outpatients are kept
informed if the surgeon is delayed in theatre.
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April 2014 to March 2015
4. CQUINS
Commissioning for Quality and Innovation is a national scheme where the commissioner sets
both national and local improvement targets for providers of commissioned services to deliver
safer more effective care.
These targets are intended to stretch and challenge the providers to make sustainable
improvements to their service. BMI Goring Hall entered into the full range of CQUINS and
through various improvement projects it has achieved the recommended target for all measures.
BMI Goring Hall Hospital achieved all the standards required for each measure in 2014-15.
CQUIN description
Result Target
Comments
Friends and family testexpand to outpatient setting
100%
Launch
survey
Developed new FFT for the outpatient setting and
implemented questionnaires in Oct 2014
Friends and Family test
improved response rate
52%
30%
The provider outperformed the target response
rate of 30%
Reducing negative
responses to Friends and
Family test
<1%
1%
The hospital outperformed the target of 1 %
through continuous monitoring and feedback of
results to all teams
Reducing harm – Pressure
ulcer incidents and urinary
tract infection rate
0%
<1%
The hospital outperformed the target, by
demonstrating a zero incident of PU and UTI
incidents through a point prevalence audit.
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April 2014 to March 2015
Dementia screening
100%
90%
The Hospital continues to demonstrate that all
patients are screened for dementia using a
nationally recognised tool
Dementia awareness
87%
85%
The Hospital outperformed the set target of 85%
of staff to attend dementia awareness training
during the year
Real-time patient feedback
100%
90%
The hospital implemented a system whereby
patient feedback was collated locally and fed back
on a weekly basis
Enhancing the patient
experience
100%
90%
The hospital implemented a plan to obtain
qualitative feedback from patients about their
perception of care delivery. This has reinforced
and support good practice.
5. National Clinical Audits
Goring Hall Hospital was eligible to participate in National Joint Registry audit and all joint
replacements are submitted to this national database. Participation and data quality remain high
as detailed below.
Data Quality Measure
Hospital
National Expected
Consent
Better Than Expected
99.6%
85.0%
Valid NHS number
As Expected
98.0%
92.0%
Time taken to enter data
Better Than Expected
5 Days
30 Days
Ninety-day mortality ratio following knee or hip replacement surgery remains low. Knee
replacement revision rates are elevated as several patient elect for partial (Unicompartmental)
Knee replacements which are then subsequently revised to full total knee replacements as their
arthritic symptoms progress.
NJR Knee Replacement
Hospital Ratio
Patient Outcomes Quality Measure
Revision Rate: Operations Apr 09 -Jul14
1.24
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National Ratio
1.00
BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
NJR Hip Replacement
Hospital Ratio National Ratio
Patient Outcomes Quality Measure
Revision Rate: Operations Apr 09 - Jul14
1.00
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BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
Priorities
Patient
Accommodation
Consulting Suite
Parking
Ophthalmology
Pain Management
Shared Decision
Making
Ward environment
Theatre capacity
PROMS
Actions
Continue rolling programme of carpet replacement and room
refurbishment for inpatient accommodation
Refurbish consulting suite waiting areas and ensure that the environment
is suitable for patients with low vision
Improve car parking facilities
Develop an ophthalmology suite that meets the needs of patients with low
vision
Review local protocols for pain management and support implementation
through training
Ensure that all inpatients have the opportunity to develop a shared
discharge goal
Room refurbishment programme. Redesign of the nurses’ station to
reduce noise disturbance
Increase theatre and day care capacity
Identify patients who have a less favorable health gain earlier in their
recovery and implement additional support to achieve an improved health
gain.
8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for the Goring Hall
Hospital for the reporting period.
Unit
Zero
Reporting Periods
(at least last two
reporting periods)
Oct 2012 – Jun 2014
National
Average
Highest National
Score
Lowest National
Score
0.9987
1.1849
0.58345
Goring Hall Hospital considers that this data is as described for the following reason:
The hospital assesses all elective admissions and has a robust system to ensure that patients
are at their optimum health state prior to surgery.
8.2 Goring Hall Hospital - patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
Reporting Periods
(at least last two
National
Average
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Highest National
Score
Lowest National
Score
BMI Goring Hall Hospital Quality Account
April 2014 to March 2015
0.112
reporting periods)
Apr 14 – Dec 14
0.0786
0.278
-0.112
Goring Hall Hospital considers that this data is as described for the following reason:
Patients receive a follow up phone call within 48 hours of discharge so that health issues can be
acted on quickly.
(ii) Varicose vein surgery (less than 30 respondents therefore not scored)
(iii) Hip replacement surgery
Unit
22.594
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
21.542
28.6
9.714
BMI Goring Hall Hospital considers that this data is as described for the following reason:
Patients access treatment later in their disease pathway and age profile of local population.
(iv) Knee replacement surgery during the reporting period.
Unit
13.753
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
16.641
24.429
5.833
BMI Goring Hall Hospital has taken the following actions to improve this patient outcome score
and the quality of its services, by ensuring that patients with less favourable outcomes are
identified sooner following surgery in order that additional rehabilitation services can be
implemented.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
BMI Goring Hall Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
NA - no pediatrics
8.3.(ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the BMI Goring Hall Hospital within 28 days of being discharged from a hospital which forms
part of the hospital during the reporting period.
NA - no pediatrics
8.4 Goring Hall Hospital’s responsiveness to the personal needs of its patients during the
reporting period.
Unit
94.8%
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
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April 2014 to March 2015
BMI Goring Hall Hospital considers that this data is as described for the following reasons:
Patients perception of quality of care is consistently high. The care teams engage in several
activities to ensure that the patient feedback is continuously monitored.
8.5 The percentage of patients who were admitted to BMI Goring Hall Hospital and who were
risk assessed for venous thromboembolism during the reporting period.
Unit
100%
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Jan 15
National
Average
Highest National
Score
Lowest National
Score
95
100
87
BMI Goring Hall Hospital will continue to monitor all patients admitted to ensure that risk
assessments continue to be completed for all patients.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within BMI Goring
Hall Hospital amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
14.7
37.1
0
BMI Goring Hall Hospital considers that this data is as described for the following reasons:
Suspected cases of C difficile are identified through application of local microbiology policies
together with ongoing monitoring of anti-microbial usage.
8.7 The number and, where available, rate of patient safety incidents reported within the BMI
Goring Hall Hospital during the reporting period, and the number and percentage of such patient
safety incidents that resulted in severe harm or death.
Number of patient safety incidents reported
Unit
Reporting Periods
National
(at least last two
Average
reporting periods)
360
Oct 13 – Sep 14
20
Highest National
Score
Lowest National
Score
139
0
BMI Goring Hall promotes active reporting of all adverse and non- adverse incidents
Number of patient safety incidents that resulted in severe harm or death
Unit
Reporting Periods
National
Highest National
Lowest National
(at least last two
Average
Score
Score
reporting periods)
1
Oct 13 – Sept 14
40.2
97
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents
per 100 Admissions)
Unit
Reporting Periods
National
Highest National
Lowest National
(at least last two
Average
Score
Score
reporting periods)
0.08%
Oct 13 – Sept 14
0.3
2.4
0.0
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BMI Goring Hall Hospital considers that this data is as described for the following reasons:
We have embedded a no-blame reporting culture that encourages staff to report incidents and
near misses. Staff receive regular feedback on incident through shared learning documents that
are discussed at team meetings. Improvements and changes are generated by the team.
8.8 The percentage of staff employed by the BMI Goring Hall Hospital during the reporting
period, who would recommend the hospital as a provider of care to their family or friends.
Unit
86.2%
Reporting Periods
(at least last two
reporting periods)
2014
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
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 BMI Goring Hall Hospital as a provider of care to
their family or friends.
Unit
83%
Reporting Periods
(at least last two
reporting periods)
Jun 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
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