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
Kings Oak Hospital
Quality Accounts Information
BMI The King’s Oak Hospital is located
in Enfield along with its sister hospital
BMI Cavell Hospital. Kings Oak
Hospital is a purpose built 47 bedded
private patient unit located within the
grounds of Chase Farm NHS Hospital.
Through partnership with our host NHS
Trust, we are able to offer a full range
of medical services with the benefit of
extensive clinical support services.
In 2014, 36% of the overall work
carried out at BMI King’s Oak Hospital
was on NHS patients.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Kings Oak 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 15th October 2013 and reported all
standards inspected (see below) were met
Standards of treating people with respect and involving them in their care
Providing care, treatment and support that meets people's needs
Standards of caring for people safely & protecting them from harm
Standards of staffing
Standards of management
Kings Oak 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. There has been development of
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
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 Kings Oak Hospital.
The focus on infection prevention and control continues under
the leadership of the Group Director of Infection Prevention and
Control and in liaison with the Infection Prevention and Control
Lead for Kings Oak
We have had: • 0 MRSA bacteraemia cases/100,000 bed days
• 0 MSSA bacteraemia cases /100,000 bed days
• 0 E.coli bacteremia 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 both hips and knees
Audits have been undertaken in Healthcare Associated Infections, Inpatient Management,
Management of equipment, and PPE which have all achieved scores of 98% and above.
Care bundles have also been implemented on the wards and in theatres around peripheral
cannula insertion and care, urinary catheter insertion and care, and surgical site infections,
again with very high results.
All audits are reported at quarterly Infection Prevention and Control Committee meetings.
Furthermore, Aseptic Non-Touch Technique (ANTT) has been introduced throughout the
hospital site and also forms part of the yearly mandatory training programme for all Clinical staff
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 staffs are
doing their job
Privacy, Dignity
Condition, Appearance
& Wellbeing
& Maintenance
89.09%
87.73%
91.97%
93.63%
87.88%
93.21%
Organization
Cleanliness
Food
National level score
97.25%
Kings Oak Hospital
96.74%
Looking at the recently published PLACE data for 2015. We can see a fall in the scores from
2014
This will form part of the patient satisfaction group moving forward to address the issues
highlighted
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, Kings Oak. 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 consistently 100% achievement
Kings Oak 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.
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, there were insufficient numbers of questionnaires returned to
provide valid data. However the hospital is committed to ensure every single patient is offered
the opportunity and support to participate if they so require and to ensure that data is posted
accurately.
April 14 – September 14
Kings Oak
England
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
N/A
N/A
N/A
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
April 14 – September 14
Kings Oak
England
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
N/A
N/A
N/A
19.401
36.103
16.702
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
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
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.
These incidents these have been monitored through our clinical governance committee
meetings and no concerns identified. Furthermore these rates are below other BMI sites of a
similar size.
From March of this year our Clinical Governance Committee meets monthly (previously it was
quarterly) and this new frequency of data monitoring allows us to be able to action any
requirement for intervention at an early stage should any trends become apparent.
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.
To improve our current level of service at Kings Oak Hospital, one of the focus points of the
service is currently catering. Future development of caterign services, as part of BMI corperate
reform, will be to intergret with an external catering contractor for the hospitals
Another area for service improvement at Kings Oak Hospital is the departure process, as part
of the patient pathway. Improvements will be to ensure the latter stage of the patients
experience is not hasted and the patient is fully prepared for discharge from the hospital. The
hospital is developing the role of a Discharge Nurse Co-ordinator
preparation for discharge
to aid in the patients
The Hospital now holds a formal Patient Satisfaction Group, this is made up from personell from
all hospital departments as this gives a comprehensive overview and partisipation in any formal
action plans that are devised to improve patient satisfaction within areas denoted as requiring
improvement form the monthly results data.
A formal action plan review is to be presented and discussed including predicted outcome
measures by Heads of Department at Managenment meetings in relation to improvement
objectives for their areas. This is a fromal process to ensure improvement is driven formally
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey, BMI
Kings Oak 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.
We are committed to drive our complaint rate down by being open and transparent with all our
patients, In light of this we have noted a small inctrease year on year for complaints at hospital
level.
Every complaint is thoroughly investigated, and a written response sent to the complainant.
Lessons to be learnt are sought through each investigation to prevent recurrence and improve
quality of care.
Strict compliance is maintianted toward not only the reporting of but the complete management
of the complaint including adherance to the time line for relpying and closure of any complaint
in line with the BMI complaint policy
4. CQUINS
Kings Oak Hospital took part in NHS CQUINs and results demonstrate full and complete
compliance with 100% achievement for VTE risk assessments, and compliance to referral back
to GP with patient letters both at 100%. Feedback for family and friends in relation to patients
experience reached and exceeded the accepted level of achievement, smoking cessation,
outpatient communication and nutritional risk assessments were monitored; the Safety
Thermometer and pain scores were monitored. and pre assessment achieved for all NHS
patients admitted to site.
5 out of 5 CQUINNS were achieved last year
Kings Oak is committed to drive this improvement for the coming year by complying to existing
and new CQUINNS
BMI Reporting Deadlines (template to NHS Commisioners): Q1 - July WD10; Q2 - October WD10; Q3 -January WD10; Q4 - April WD10
Friends and Family 1.1
Quarter 1
Quarter 2
Early Implementation of FFT - show
Description of
implementation by October 2014 to daycase and
Indicator
outpatients.
FFT - achieving early implementation / phased
Performance
expansion in line with national milestones (Y/N)
Apr-14 May-14 Jun-14
Numerator
The number of patients recorded as having a fall as
measured using the NHS Safety Thermometer on the day of
each monthly survey.
Denominator
Total number of patients surveyed on the day.
Q1
Jul-14 Aug-14 Sep-14
Yes
Implementation by Q3
Quarter 1
Target
Yes
Yes
Q2
Yes
Q1
Jul-14 Aug-14 Sep-14
Quarter 1
6 or less
Q2
Performance
0.0
Q1
0.0
0.0
Yes
Q3
Jan-15
Yes
Yes
76%
77%
Q2
0.0
100%
0.0
Yes
Q4
Yes
Quarter 4
Q3
Jan-15
85%
56.00%
Feb-15 Mar-15
Q4
89.40% 56.00% 67.13%
Quarter 4
Oct-14 Nov-14 Dec-14
0.0
Feb-15 Mar-15
Yes
Quarter 3
Jul-14 Aug-14 Sep-14
0.0
Yes
Oct-14 Nov-14 Dec-14
Quarter 2
Apr-14 May-14 Jun-14
0.0
Yes
Quarter 3
37.90% 57.10% 31.80% 42.27% 33.30% 70.00% 11.00% 38.10%
Target
Oct-14 Nov-14 Dec-14
Quarter 2
Apr-14 May-14 Jun-14
Safety Thermometer
Description of
Reduction in the falls
Indicator
Quarter 4
Target
Friends and Family 1.2
Description of Increased or maintained response rate, Q2 25%
and Q4 30%
Indicator
Increased response rate 20% by Q1 and 30% by
Performance
Q4
Quarter 3
Q3
Jan-15
1.0
Feb-15 Mar-15
0.0
0.0
Q4
0.0
0.0
100.00% 100.00% 100.00% #DIV/0! 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%
Discharge Summary 1.1
Quarter 1
Quarter 2
Quarter 3
Quarter 4
To report on the number of discharge
Description of
summaries sent to GPs within 24hours of the
Indicator
Performance
Target
patient being discharged.
Apr-14 May-14 Jun-14
Percentage of discharge summaries send to GPs
within 24hours.
100.00% 100.00% 100.00% 100.00%
Q1
Jul-14 Aug-14 Sep-14
100%
100%
100%
Q2
100%
Oct-14 Nov-14 Dec-14
100%
100%
100%
Q3
Jan-15
Feb-15 Mar-15
Q4
100% 100.00% 100.00% 100.00% 100.00%
5. National Clinical Audits
Kings Oak 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.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
•
Ongoing engagement with NHS commissioners to enhance patient choice and service
delivery to NHS patients will be measured by agreed quality indicators
•
Audit compliance with Care Bundles to ensure that these have been effectively
implemented and this will be measured by infection rates.
•
Extension of collection of PROMS to include hip and knee replacement all patients
•
Further develop the availability of performance and quality indicators for patients,
consultants, referrers and commissioner
8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for Kings Oak Hospital
for the reporting period.
Unit
Reporting Periods
National
Highest National
Lowest National
(at least last two
Average
Score
Score
reporting periods)
0
April 2014-March 2015
0.9987
1.1849
0.58345
This value represents the rate of mortalities at the hospital in the reporting period. This was
below the lowest national score.
8.2 The (Kings Oak) patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
NA
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
0.0786
0.278
-0.112
There were minimum numbers going through the process for groin surgery so the BMI Kings
Oak Hospital was unable to be scored on this element
The Kings Oak intends to promote completion of PROMS with every patient led by the Preassessment team
(ii) Varicose vein surgery
Unit
NA
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
-7.395
-1.957
-12.571
National
Average
Highest National
Score
Lowest National
Score
21.542
28.6
9.714
No data was provided for varicose veins
(iii) Hip replacement surgery
Unit
NA
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
(iv) Knee replacement surgery during the reporting period.
Unit
NA
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
As with groin surgery above there were minimum numbers going through the process for hip
and knee replacement surgery so the BMI Kings Oak Hospital was unable to be scored on this
element.
The Kings Oak intends to promote completion of PROMS with every patient led by the Preassessment team
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
Kings Oak within 28 days of being discharged from a hospital which forms part of the hospital
during the reporting period.
Unit
0%
Reporting Periods
(at least last two
reporting periods)
Apr 14 - Mar 15
National
Average
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
Kings Oak within 28 days of being discharged from a hospital which forms part of the hospital
during the reporting period.
Unit
0.3266
rate per
100
admissions
Reporting Periods
(at least last two
reporting periods)
April 14 – Mar 15
National
Average
Highest National
Score
Lowest National
Score
10.01
14.51
5.54
The rate for The BMI Cavell Hospital are well below the national average. Re-admission rates
continue to be monitored on a monthly basis to observe for trends and reported monthly through
the Clinical Governance Committee and MAC.
8.4 The Kings Oak responsiveness to the personal needs of its patients during the reporting
period.
Unit
96.85
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
This figure exceeds the highest national score. Responsiveness continues to be monitored on a
monthly basis through patient satisfaction data, monitoring of patient satisfaction action plans at
monthly meetings, and daily patient visits enabling immediate action to rectify any issues raised
8.5 The percentage of patients who were admitted to Kings Oak 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
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Kings Oak
amongst patients aged 2 or over during the reporting period.
Unit
0.0001
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
Again this meets the lowest national score and will continue to be maintained through strict
adherence to infection prevention and control practices, policies, surveillance and audits, and
working closely with our Consultant Microbiologist
8.7 The number and, where available, rate of patient safety incidents reported within the Kings
Oak 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
187
(count)
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
Lowest National
Score
20
139
0
Figures given for Kings Oak Hospital are for the period of April 2014 – March 2015 which would
explain the high numbers of incidents
The hospital has a healthy incident reporting and incident feedback culture with incidents being
monitored on a daily basis.
Rate of patient safety incidents reported (Incidents per 100 Bed Days)
Unit
5.6392
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
Lowest National
Score
3.589
7.496
0.0245
This is higher than the national average but we have had a drive toward complete transparency
and delivering an open and honest reporting culture within the hospital. The staffs are becoming
confident to report more frequently as a learning tool rather than previously as a blame culture.
Training is much more apparent on how to report, this is monitored on a daily basis.
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
40.2
97
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100
Admissions)
Unit
0%
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
8.8 The percentage of staff employed by the (name of hospital) during the reporting period, who
would recommend the Kings Oak as a provider of care to their family or friends.
Unit
N/A
Reporting Periods
(at least last two
reporting periods)
2014
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
There are no figures available for staff recommendations as these are not scored independently
9. Non-Mandatory Quality Indicators
9.1 The percentage of patients who received care as inpatients during the reporting period, who
would recommend the Kings Oak as a provider of care to their family or friends.
Unit
79 %
Reporting Periods
(at least last two
reporting periods)
April 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
The Management Team at daily brief have a constant focus on the Patient satisfaction return
rates both long form and post card as vital data for patient satisfaction is gained from both
sources to the Satisfaction group. Customer satisfaction sessions are to be driven going forward
for staff and customer engagement sessions.