Chief Executive’s Statement
I am pleased to welcome you to our Quality Accounts 2015.
Now in their sixth year, Quality Accounts continue to provide a truly objective metric for us, and others, to gauge the quality of our 59 hospitals and the services they provide against a broad range of criteria.
The past year has seen another step change in the way healthcare providers are externally challenged on the quality they provide.
Following a spate of high profile controversies around patient safety, the Care Quality Commission, the UK’s health regulator, has introduced a new inspection regime designed to raise standards.
No healthcare provider can afford to be complacent and whilst I believe BMI’s hospitals provide safe and effective care, we should always be striving for improvement.
To this end we recently introduced a new Quality Strategy, which articulates how we will provide the best possible care and strive for continual improvement, and live up to our brand promise to be “serious about health, passionate about care”. Its four core themes – safety, clinical effectiveness, patient experience and quality assurance – provide our staff with the platform to consistently deliver the care patients, their insurers, and commissioners expect and deserve.
BMI hospitals have been enthusiastic participants in the pilot programme of the new CQC inspection regime for private providers, and to ensure our facilities are prepared we have developed a selfassessment tool to enable hospitals to compare their perceptions of themselves with those of the external inspectors. The rigorous inspection process itself also underpins the sharing of best practice between hospitals which further drives improvement and consistency.
BMI Healthcare strives to provide the best care but the ultimate arbiters of whether we succeed are our patients. We are committed to monitoring every aspect of the care we provide, and the results of the detailed questionnaires we ask patients to complete inform improvement. We aim to provide a consistent, high quality patient experience and an environment that empowers our consultants to excel. Providing a dependably high quality of care requires constant focus on improvement; the most recent independent research conducted for BMI shows that over 98% of our patients rate their care as excellent or very good.
The information available here has been reviewed by the Clinical Governance Board and I declare that as far as I am aware the information contained in these reports is accurate. Finally I would like to thank all the staff whose application, professionalism and ceaseless commitment to improvement is recognized here and in the positive experiences of the patients we care for. Since I joined BMI late last year, I have witnessed this firsthand on my many visits to our hospitals and I am committed to ensuring we build on that success.
Jill Watts, Group Chief Executive

BMI The Princess Margaret Hospital, in Windsor, Berkshire has 78 beds with rooms furnished to a high standard and offering the privacy and comfort of en-suite facilities, Free view TV and telephone. The hospital has four operating theatres, 17 outpatient consulting rooms, a dedicated day care ward, chemotherapy unit, pharmacy, new purpose built endoscopy unit, physiotherapy and imaging departments with onsite MRI and CT.
Our consultants are supported by caring and professional medical staff, including highly qualified nursing teams and Resident Medical Officers 24 hours a day, ensuring the highest quality care in a friendly and comfortable environment.
The new purpose built Endoscopy unit will be opened on the 15 th
June 2015.
This Endoscopy unit has one endoscopy theatre, six recovery bays which are separated into 2 same-sex recovery bays. The new unit has been designed and built to be JAG compliant and the hospital will be working towards applying and achieving JAG accreditation.
BMI The Princess Margaret Hospital continues to participate in the Choice Network for NHS patients offering a range of services for patients to choose their hospital and surgeon. NHS patients accounted for 11% of the overall caseload at PMH in 2014-15
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The Princess Margaret Hospital is registered as a location for the following regulated services:-

•
Treatment of disease, disorder and injury
•
Surgical procedures
•
Diagnostic and screening
The hospital appointed a Quality and Risk Manager in 2015 to coordinate the activities across the hospital to support clinical governance initiatives and reassessing compliance with the 5 new CQC Domains.
•
Safe
•
Effective
•
Caring
•
Responsive
•
Well led
The 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 analyze 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.

1.1 Infection prevention and control
The focus on infection prevention and control continues under the leadership of the Group
Director of Infection Prevention and Control, in liaison with the Princess Margaret hospital’s
Director of Infection Prevention and nominated IPC teams.
We have had: -
•
Zero cases of MRSA bacteremia in the last year (NHS 1.17cases/100,000 bed days).
•
Zero cases of MSSA bacteremia /100,000 bed days.
•
Zero cases E.coli bacteremia cases/ 100,000 bed days.
•
Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
Monthly audits are undertaken across the hospital for departmental Infection Prevention and control and Environmental measures and the annual average score is 98%. Key actions around sourcing of corporate patient information documentation on infections and promoting communication between the laboratory team and the IPC Lead nurse.
There has been a focus on Antimicrobial Stewardship during the year and antibiotic audits are conducted regularly during the year to review compliance to prescribing in relation to antibiotics.
The Pharmacy department continue to undertake monitoring of antibiotic prescribing and is due to undertake another audit in the next quarter.
Care Bundles in place at the Princess Margaret include:
•
peripheral line insertion and ongoing care – with monthly audits overall score of 100%
•
urinary catheter insertion and ongoing care - with monthly audits overall score of 100%
•
surgical site care intraoperative and post-operative with monthly audits overall score of
97%
•
central line insertion / ongoing care. 100%
All these care bundles are measured by regular audits undertaken by Infection Prevention and
Control link practitioners with an overall average of 98% compliance. Key themes are around documentation and record-keeping.

•
Hand Hygiene audit is undertaken by each clinical department monthly and the overall score was an improvement on the previous quarter at 97%.
.
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 2015 the hospital undertook a PLACE audit, which is the system for assessing the quality of the patient environment, replacing the old Patient Environment Action Team (PEAT) inspections.
The assessments involve patients and staff who assess the hospital and how the environment supports patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on the care environment and does not cover clinical care provision or how well staff are doing their job.
The results will show how hospitals are performing nationally and locally. The PLACE audit was undertaken at the Princess Margaret hospital in April 2015 and 2 patients took part alongside 2 staff members and the results were positive. Specific actions following this focused on further review of some internal signage. Another action was around some improvements to external lighting, and repair of overhead lighting in some of the patient rooms.
The results are shown in the below table and indicated improvement from the previous year’s same audit. Results from previous PLACE audit.
Cleanliness Food Privacy, dignity and wellbeing
90.91%
Condition, appearance and maintenance
98.28% 100% 92.51%
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, The Princess Margaret 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 assess every patient who is admitted to our facility by monthly audits of patient notes and the results of our audit on this has shown high compliance with a yearly average of 97% due to no information available in November.

The Princess Margaret 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.
VTE RCA There has been no VTEs reported in 2014-15.
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 program..
The Princess Margaret hospital ensures all eligible NHS patients are encouraged to complete the PROMs questionnaire prior to admission, asking at the Pre-assessment appointment, however the numbers of patients eligible at the hospital, are extremely low. This has resulted in no Hospital data being available in the annual results for the Oxford Hip Score.
April 14 – September 14
BMI The Princess Margaret
Oxford Hip Score average
Q1 Q2
Health gain between reporting periods
*Numbers too small to extrapolate
* * information
England 18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
Oxford Knee Score average
April 14 – September 14
BMI The Princess Margaret
Q1
*
Q2
*
Health gain between reporting periods
*Numbers too small to extrapolate information
England 19.401
36.103
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
16.702

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.
Due to our small numbers of Surgical procedures for hips and knee replacements undertaken, it has been a challenge to meet all elements of: a. Maintaining good pre-operative hydration by introducing Carbohydrate loading
drinks pre surgery to enhance surgical outcomes b. Maintaining normothermia pre and post operatively by monitoring pre and post-
operative temperatures of patients. c. Early mobilisation within 12-18 hours post operatively. d. Participate in their discharge planning by achieving average length of stay of 2.75 days under the national average of 3.5 days.
Early mobilization achieved 100% compliance within 12-18 hours post – operatively.
We aim to improve the use of peripheral care bundles when inserting a peripheral line in order to meet all required standards outlines in care bundles.
Rationale: Improvement: to improve audit compliance in meeting all the standards with the insertion /ongoing care for these devices.
For the past year we have achieved 100% compliance with peripheral line care bundles.
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. Our figures remain very low. We always encourage patients to contact the hospital after discharge with any concerns they may have and undertake post discharge telephone calls.
The hospital continues to improve to work towards improving patient outcomes by the ERP
Process and this is regularly reviewed.

2.1 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
BMI The Princess Margaret Hospital
Arrival process
Nursing care
Catering
Quality of care
Consultant / Anaesthetist
Consultant Surgeon / Physician
Accommodation
Discharge procedure
Met / exceeded expectation
Recommendation
3.2 Complaints
(definitely + probably)
2013-4
94.1
98.4
98.5
96.1
95.6
85.1
90.2
97.2
97.9
97.8
2014-5
94.4
98.3
98.9
95.4
93.6
85.7
91.3
97.2
97.6
98.9
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Princess Margaret 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.

All complaints and trends are reviewed at clinical governance committee meetings with actions agreed.
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Financial
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Clinical
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Other
The National CQUINs for the Princess Margaret hospital in 2014-5 were:
1. The Safety Thermometer
To maintain 100% harm free care for all 4 Safety Thermometer indicators. The Princess
Margaret Hospital achieved 100% submission compliance over 2014-2015 with no reported Pressure ulcers, Patient fall with harm, urinary catheters developing into UTI’s and no reported VTEs.
2. Friends and family
The 2 targets were to maintain at 30% and also to increase response rate to 40% by the end of the year. The Princess Margaret Hospital maintained response rate and continues to encourage users of the service to complete the Friends and Family questions prior to leaving the hospital.

The locally agreed CQUINs were:-
1. To further implement and embed enhanced recovery (ERP) for his and knee arthroplasty and support discharge average of 3.5 days.
The Princess Margaret Hospital achieved the discharge average, and early mobilisation aspect of this CQUIN but is continuing to work with consultants regarding wider introduction of carbohydrate load drinks pre-operatively.
2. To improve the use of peripheral line care bundle when inserting a peripheral line in order to meet all the standards.
Monthly audits were conducted throughout the year and this was achieved
The Princess Margaret Hospital was only eligible to participate in National Joint Registry audit and all joint replacements are submitted to this.
No NHS patients were recruited to take part in research.
PMH has a new purpose built endoscopy unit is currently awaiting JAG accreditation
Preadmission
Focus will continue on this as an important aspect of the patient journey and actions proposed to increase patients’ telephone and or face-to-face assessments with an emphasis on patient education . PMH plan so have 100% patients pre admitted by 2016
Outpatient Areas
With outpatient activity continuing to grow year on year, the hospital will be appointing a Director of Operations in June 2015 and will focus on developing the Outpatient Minor Procedures
Theatre, refurbishing the existing Minor Procedures Theatre and refurbishing the Outpatient
Consulting Rooms.
Enhanced Recovery Program
The hospital will continue to develop initiatives in relation to ERP, with the focus on measures to continually improve our patient outcomes and satisfaction scores

7.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI Princess
Margaret Hospital for the reporting period.
Unit Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
* Oct 2012 – Jun 2014 0.9987 1.1849 0.58345
*The BMI Princess Margaret Hospital considers that this data is as described for the following reasons: patient numbers were less than 30.
8.2 The BMI Princess Margaret Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
*
Reporting Periods
(at least last two reporting periods)
Apr 14 – Sept 14
National
Average
0.0786
Highest National
Score
0.278
Lowest National
Score
-0.112
*The BMI Princess Margaret Hospital considers that this data is as described for the following reasons: Insufficient data less than 30 patients
(ii) Varicose vein surgery
Unit 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
*The BMI Princess Margaret Hospital considers that this data is as described for the following reasons: Insufficient data less than 30 patients
(iii) Hip replacement surgery
Unit
*
Reporting Periods
(at least last two reporting periods)
Apr 14 – Sept 14
National
Average
21.542
Highest National
Score
28.6
Lowest National
Score
9.714

*The BMI Princess Margaret Hospital considers that this data is as described for the following reasons: Insufficient data less than 30 patients
(iv) Knee replacement surgery during the reporting period.
Unit Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
* Apr 14 – Sept 14 16.641 24.429 5.833
*The BMI Princess Margaret Hospital considers that this data is as described for the following reasons insufficient data less than 30 patients
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
BMI Princess Margaret Hospital 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 11 - Mar 12
National
Average
11.45
Highest National
Score
14.35
Lowest National
Score
7.96
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of the BMI Princess Margaret Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period.
Unit
1%
Reporting Periods
(at least last two reporting periods)
Apr 11 – Mar 12
National
Average
10.01
Highest National
Score
14.51
Lowest National
Score
5.54
8.4 The BMI Princess Margaret Hospital responsiveness to the personal needs of its patients during the reporting period.
Unit
80%
Reporting Periods
(at least last two reporting periods)
2013-2014
National
Average
68.7
Highest National
Score
85
Lowest National
Score
54.4

8.5 The percentage of patients who were admitted to BMI Princess Margaret Hospital and who were risk assessed for venous thromboembolism during the reporting period.
Unit Reporting Periods
(at least last two
National
Average
Highest National
Score
Lowest National
Score
98% reporting periods)
Apr 14 – Jan 15 95 100 87
The BMI Princess Margaret Hospital considers that this data is as described for the following reasons : There were some patients who were emergency admissions and therefore not VTE pre assessed.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the BMI
Princess Margaret 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
14.7
Highest National
Score
37.1
Lowest National
Score
0
8.7 The number and, where available, rate of patient safety incidents reported within the BMI
Princess Margaret 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
Lowest National
Score
Unit Reporting Periods
(at least last two reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
0 20 139
Rate of patient safety incidents reported (Incidents per 100 Bed Days)
Unit
Unit
0
Reporting Periods
(at least last two
Reporting Periods
(at least last two reporting periods)
Oct 13 – Sept 14
National
Average
Highest National
Score
0 reporting periods)
Oct 13 – Sep 14 3.589 7.496
Number of patient safety incidents that resulted in severe harm or death
National
Average
40.2
Highest National
Score
97
0
Lowest National
Score
0.0245
Lowest National
Score
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
0.3
Highest National
Score
2.4
Lowest National
Score
0.0
8.8 The percentage of staff employed by the (name of hospital) during the reporting period, who would recommend the BMI Princess Margaret Hospital as a provider of care to their family or friends.
Unit Reporting Periods
(at least last two
National
Average
Highest National
Score
Lowest National
Score
80% reporting periods)
2014 64.58 96.43 33.73
9.1 The percentage of patients who received care as inpatients or discharged from A &E during the reporting period, who would recommend the BMI Princess Margaret Hospital as a provider of care to their family or friends.
Unit
80%
Reporting Periods
(at least last two reporting periods)
Jun 13 – Jan 14
National
Average
66.23
Highest National
Score
94.38
Lowest National
Score
35.63