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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Hospital Information
BMI Hendon Hospital is a 29 bed acute general hospital situated in Hendon, London and is
easily accessible, with transport links from central London and surrounding areas. The hospital
offers the privacy and comfort of en-suite facilities, satellite TV and telephone, ten consulting
rooms, two operating theatres, minor ops rooms, outpatient cardiology, physiotherapy and an
onsite pharmacy department. The hospital also has an imaging suite with a 1.5t MRI and Dental
CT scanner.
BMI Hendon Hospital offers choose & book NHS services for diagnostic and orthopaedic,
urology, gynaecology, ophthalmic, endoscopy and general surgery. We have a NHS musicians’
clinic for upper limb surgery and sports injury for 18yrs and above. BMI Hendon Hospital sees in
the region of 40% of NHS patients to private patients.
The Physiotherapy department offers a unique Whole Body Cryotherapy service (WBC) which is
the exposure of the entire body to extreme cold at approximately -80 degrees Celsius, alongside
a state-of-the-art Alter-G Anti-gravity treadmill and shockwave therapy.
The Consulting suite has ten consulting rooms, two minor procedure clinics offering Walk-inWalk-out services for Hysteroscopy and Cystoscopy services. One-stop Dermatology/Plastics
shop. We continue to offer Paediatric services for children age 3-16, however this is for
Consultation only and no interventional procedures are facilitated on site.
Outpatient Cardiology service including
Electrocardiogram and Echocardiograms.
Cardiac
MRI,
Electrocardiogram,
Stress
The Imaging department has an MRI, Dental CT scanner and ultrasound facilities. The unit also
has a Mammography service which supports our Breast Surgeons. With the equipment
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available in the Imagining Suite, we are able to provide interventional procedures such as
Barium Swallows, Joint injections and Urodynamics.
There is a new out of hours GP service called “EdgCARE”, situated on the 2nd Floor at BMI
Hendon, this creates referrals through multiple departments on site and it is hoped that this
service will grow, to support both the local community and BMI Hendon.
Also located at BMI Hendon is “CDS”, Clinical Diagnostic Services who provide scanning
services. This service is led by a renowned “Consultant Ultrasound Specialist” and leads to
referrals also, on site.
Brent Community Ophthalmology Services (BCOS) is a new dedicated community outpatient
service for the London Borough of Brent. The service was set up to treat common eye
problems, and to manage a range of short and long term eye conditions including, Blepharitis,
Blurred Vision, Dry eyes, and Eye/eyelid lesions. Field defects, Floaters, Glaucoma, Retinal
lesions and Watery eyes.
There are 2 community based sites (Sudbury and Willesden) open 6 days a week. Consultant
led multidisciplinary team delivery of care, Urgent appointments available within 24 hours,
routine appointments within 4 weeks. There is a choice of secondary care providers if onward
referral is necessary and support is also available through a GP advice line/on call service. An
on-site admin support for rapid documentation turnaround is also available.
Choose and Book referrals can be made via the online Choose and Book system. Choose and
Book manual referrals can be sent via NHS.net accounts or by fax.
NHS patients represented over 40% of our admissions for the financial year.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Hendon Hospital is registered as a location for the following
regulated services:Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Family Planning
The CQC carried out an unannounced inspection on 29th October 2013 and reported on the
following:
There were two patients admitted to the in-patient ward on the day of our visit and we were able
to speak with one of them. We also spoke with several patients who were attending out-patient
appointments. Everyone told us they were happy with the care and treatment provided. For
example, one patient told us they had been “treated perfectly.” In the out-patient department a
patient told us their treatment had been explained clearly and they felt “comfortable asking
questions.” Patients told us they felt safe using the service and had confidence in the staff.
Everyone said they would recommend the hospital to others. Patients considered the service
was clean and hygienic. For example, one patient described the hospital as “spotless.” There
had been no cases of hospital acquired infection in 2013. There were effective systems in place
to reduce the risk of infection. There was an effective system in place for assessing and
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monitoring the quality of the service patients received. Records kept by the service were
accurate and fit for purpose
Care and welfare of people that use services
Safeguarding people who use services from abuse
Cleanliness and Infection Control
Assessing and monitoring the quality of service provision
Records.
BMI Hendon 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 operationalized.
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
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1.1 Infection prevention and control
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 at BMI
Hendon Hospital.
We have had: 1 case of MRSA bacteraemia in the last year (NHS
1.17cases/100,000 bed days).
No MSSA bacteraemia or E-Coli cases have been reported.
No reports of C-Diff infections which have been apportioned to
BMI Hendon Hospital.
SSI data is also collected and submitted to Public Health England for orthopaedic surgical
procedures. Our rates of infection are:
0% Hips
0% Knees
We audit our Infection Prevention within BMI Hendon Hospital by completing monthly audits.
Each month there is a different focus regarding Infection Prevention audits. The audits are
always reviewed and action plans are put in place to improve the Infection Prevention of the
Hospital.
The individual departmental cleaning records are now maintained and audited accordingly. We
now have in place a robust Infection Prevention and Control Committee which is supported by
our Microbiologist. We have regular Infection Prevention meetings, therefore involving the link
nurses within their own specialty to improve our Infection control.
We are proactive with the VIP scoring and use the catheter care bundle. We now own a bladder
scanner which enhances the clinical outcome of patients that are in retention post operatively;
therefore ensuring that our patients are given gold standard care.
Due to our robust pre-assessment pathway we are able to screen and manage any clinical
complications prior to the patients being admitted. We have a pathway to ensure all MRSA
patients are treated prior to the admission to hospital.
We are proactive with our hand hygiene training and hold regular hand washing days
incorporated in our mandatory training days, along with highlighting the National Day. There is a
dedicated staff communication board for staff to view regular IPC updates. We strive to train all
our staff with the Infection Prevention training through BMI. This has both practical and
theoretical components.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
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The graph below shows our room cleanliness.
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 a 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 members are doing their job.
BMI Hendon has recently completed the 2015 PLACE audit with positive feedback received
from the patients interviewed. One of our areas highlighted for improvement was the Catering
services which have now been outsourced to Compass. Although we scored lower than
expected in the section for Privacy and Dignity, it was on points where we do not have the
facilities within BMI Hendon to facilitate these requirements, i.e. The provision of an onsite
Chapel.
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 Hendon 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 and the results of our audit on
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this has shown that the continued usage of these risk assessments, patient information leaflets,
prophylaxis protocols, training and continuous audit, demonstrates full and ongoing compliance,
therefore minimizing the risks to our patients. BMI Hendon Hospital VTE results show 100%
compliance and we are happy to report that we have had no patients with reported VTEs that
we are aware of.
VTE is a standing agenda item on our bi-monthly Medicines Management Committee.
BMI Hendon Hospital reports the incidence of 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. The
outcomes of these are measured through monthly audit, non-compliance addressed at
Integrated Governance Board and MAC meetings.
2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Although information pertaining to BMI Hendon Hospital is unavailable from PROMs for this
reporting period, all patients, including those referred from the NHS, are actively encouraged to
complete and return the Quality Health questionnaire. BMI Hendon Hospital values the opinion
of all patients and strives to continually improve our quality of care, whilst respecting the
opinions of our customers whether they are referred privately or from the NHS.
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.
Currently this programme is only for Total Hip and Knee surgery, this applies to both NHS and
private patients.
At BMI Hendon Hospital the Enhanced Recovery programme continues to be successful and
has been embraced by the Consultants.
The Hospital and the Pre-assessment team work closely with Vitaflo who provide the preloading drinks and full explanation and instructions given by pre assessment staff.
It has been noted that within the last year, we have had only one report of a day case patient
converting to an overnight stay due to Nausea and Vomiting.
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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.
Due to the trend of unplanned re admissions we reviewed our reporting practice and it was
apparent that we were over reporting by incorrectly classifying the readmission of elderly
patients with medical comorbidities as unplanned readmissions. This has now been reported
through the Clinical Governance Board and correct reporting practices have been cascaded to
staff.
We are pleased to report that we have had no unplanned returns to theatre during this period.
3. Patient experience
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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.
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Hendon 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.
The table below shows the complaints in the quarter of January to March 2014.
The table summarizes all complaints by type and department.
A total of 9 complaints have been received, this represents 1.29% of all inpatient admissions
during this quarter which is a 0.3% reduction for the comparable period in the previous year.
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All of the complaints have been responded to within the Complaints Policy timescale.
Note: Some of the complaints are related to several areas and departments.
Customer Care
Environment
Patient Administration
Patient Care
Clinical
Outcome
Finance
Consultant
Ward
2
Radiology
Catering
Oncology
Reception
Housekeeping
Appointments
5
Physiotherapy
Outpatients
1
1
Admissions
Theatres
Car Park
4. CQUINS
BMI Hendon Hospital took part in CQUINs for North Central London (NCL), and East of England
(EofE).
NCL:
VTE risk assessments
Friends and Family
Smoking cessation
Nutritional Risk Assessments
Catheter care bundles
EofE:
VTE risk assessment
Friends and Family
Safety thermometer
Catheter care bundles
Post discharge Phone calls
Lifestyle changes.
All of these were monitored and for both CQUINs, BMI Hendon Hospital was either mostly or
fully compliant with noted improvement for the completion of post-operative phone calls.
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5. National Clinical Audits
BMI Hendon Hospital was only eligible to participate in National Joint Registry audit and all joint
replacements are submitted to this. BMI hospital data is from page 196 onwards in attached
latest NJS report. Use this if appropriate with your narrative on the data and any improvement
plans.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and Improvement
•
•
•
•
•
•
The continuous refurbishment of patient rooms.
Development and provision of a dedicated ambulatory care unit.
On-going engagement with NHS commissioners to enhance patient choice and service
delivery to NHS patients will be measured by agreed quality indicators.
Audit compliance with IPC to ensure that these have been effectively implemented and
this will be measured through audit of infection rates.
Further develop and enhance availability of performance and quality indicators for
patients, consultants, referrers and commissioners.
Improve and maintain our patient satisfaction scores with admission, pain control and
discharge process and overall quality of Nursing Care.
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for BMI
Hendon Hospital for the reporting period.
Unit
Reporting Periods
(at least last two
reporting periods)
National
Average
Highest National
Score
Lowest National
Score
0
Oct 2012 – Jun 2014
0.9987
1.1849
0.58345
BMI Hendon Hospital considers that this data is as described as we predominantly take day
cases and we pre-assess all our patients. All patients are pre-assessed and no ASA score is
taken above 2.
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8.2 Due to low numbers of patients attending for the following surgeries at BMI Hendon
Hospital, we do not have patient reported outcome measures scores for:
Varicose vein surgery
Hip replacement surgery
Knee replacement surgery
However, as discussed earlier in this report, we have a robust Pre-Assessment and ERP
programme in place which benefits the patient by improving their recovery pathway.
8.3(i) BMI Hendon Hospital does not admit children under the age of 16, therefore we had no
re-admissions for any child under the age of 15.
8.3(ii) 6 patients aged 15 or over were readmitted to BMI Hendon Hospital within 28 days of
being discharged from April 2014 to March 2015.
Unit
Reporting Periods
(at least last two
reporting periods)
National
Average
Highest National
Score
Lowest National
Score
2
Apr 14 - Mar 15
11.45
14.35
7.96
Following investigation, it was found that there was no trend connecting these incidents and the
factors for re-admission were in general due to potential risks associated with surgery
performed.
8.4 The responsiveness of BMI Hendon Hospital to the personal needs of its patients during the
reporting period was 81%, well above the National average.
Unit
81%
Reporting Periods
(at least last two
reporting periods)
2014-2015
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
Although the score is above the national average, BMI Hendon Hospital will aim to continuously
improve this score.
8.5 We are pleased to report that 100% of patients who were admitted to BMI Hendon Hospital
from April 2013 to March 2014 were risk assessed for venous thrombo-embolism during the
reporting period.
Unit
100%
Reporting Periods
(at least last two
reporting periods)
Apr14 –Jan 15
National
Average
Highest National
Score
Lowest National
Score
96
100
79
The importance of VTE assessment is discussed at ward meetings and corporate VTE audits
are in place. A corporate audit tool is used to monitor VTE activity monthly. Our Pharmacy team
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liaises with appropriate Consultants regarding correct prescription of VTE prophylaxis. Going
forward in 2015, any pharmaceutical updates will be distributed to relevant departments along
with sign off sheets which staff members must read and sign to ensure that they are kept up to
date with any changes. VTE is an agenda item at the Medicines Management Committee
meetings on site.
8.6
No reports of C-Difficile reported.
8.7
Following a score in last year’s report of 53 adverse clinical incidents, we have raised
awareness of the importance of incident reporting and this is reflected in the increased score
below. A newly appointed Ward Manager has raised the profile of incident reporting and
together with the Director of Clinical Services (DoCS) are ensuring that responsive actions are
taken and learning shared to improve the patient outcome while ensuring patient centered care.
The “6 C’s” which is embedded in the Clinical Strategy is shared and promoted within both the
clinical and non-clinical staff across the hospital, with the DoCS facilitating a “DoCS Surgery”
sessions where actions and learning from recently undertaken Root Cause Analysis (RCA) are
shared and discussed.
There were 88 adverse clinical incidents reported at BMI Hendon Hospital from April 2014 to
March 2015. There were 69 Non Adverse clinical incidents also during this period. The
importance of reporting non adverse incidents, as well as adverse incidents is reiterated at
every opportunity ensuring necessary processes/actions are introduced at BMI Hendon
Hospital, which ultimately reduces potential risks.
The number of patient safety incidents reported at BMI Hendon Hospital was slightly greater
than the national average.
Unit
88
Reporting Periods
(at least last two reporting
periods)
Apr 14-15
National
Average
Highest National
Score
Lowest National
Score
44.55
1,810
0
We are happy to report that we had no patient safety incidents that resulted in severe harm or
death
Unit
0
Reporting Periods
(at least last two reporting
periods)
Apr 14-15
National
Average
Highest National
Score
Lowest National
Score
0.64
28
0
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Percentage of patient safety incidents that resulted in severe harm or death
Unit
0%
Reporting Periods
(at least last two reporting
periods)
April 2014-15
National
Average
Highest National
Score
Lowest National
Score
0.9
2.9
0.0
The importance of an open, no blame culture in relation to incident reporting is important at BMI
Hendon Hospital. Staff members are reminded at departmental meetings and via staff forum to
report any incidents, including near misses to their Heads of Department and on Sentinel.
8.8 The percentage of staff employed by BMI Hendon Hospital during the reporting period, who
would recommend us as a provider of care to their family or friends.
Unit
72%
Reporting Periods
(at least last two reporting
periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
Note: unfortunately the current numbers were unavailable at the time the report is being
published, therefore we are submitting the 2013 numbers.
9. Non-Mandatory Quality Indicators
9.1 81% of patients, who received care as inpatients from June 2014 to January 2015, would
recommend BMI Hendon Hospital as a provider of care to their family or friends.
Unit
81%
Reporting Periods
(at least last two reporting
periods)
June 14 – Jan 15
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
Although greater than the national average, we aim to improve this score moving forward.
Lower scores were allocated to accommodation and catering in most cases. An on-going
redecoration programme is in place and again we are continually aiming to improve our scores.
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