BMI ROSS HALL HOSPITAL
QUALITY ACCOUNTS
APRIL 2014 – 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
Hospital Information
BMI Ross Hall Hospital in Glasgow is part of BMI Healthcare, Britain's leading provider
of independent healthcare with a nationwide network of hospitals & clinics performing
more complex surgery than any other private healthcare provider in the country. Our
commitment is to quality and value, providing facilities for advanced surgical procedures
together with friendly, professional care. BMI Ross Hall Hospital, aim is to provide the
highest standards in all aspects of patient care. This includes ensuring unequalled
attention to hygiene and involving patients in the process to minimise any risks of
infection.
The hospital has 101 ensuite rooms each with bathroom, telephone and television. It
has four operating theatres, one minor procedures theatre, a high dependency unit/ five
bed intensive care unit, a day chemotherapy unit and an endoscopy unit.
The hospital offers an extensive range of treatments, including cardiothoracic,
colorectal, cosmetic, gastroenterology, orthopaedic surgery, plastic surgery and general
surgery.
Ross Hall Hospital sees both inpatients and outpatients and offers a paediatric service
as required.
These facilities combined with the latest in technology and on-site support services;
enable our consultants to undertake a wide range of procedures from routine
investigations to complex surgery. This specialist expertise is supported by caring and
professional medical staff, with dedicated nursing teams and Resident Medical Officers
on duty 24 hours a day, providing care within a friendly and comfortable environment.
The building is situated within a residential area of Glasgow, with parking available on
site, close to public transport and local amenities. The hospital cares for PMI and Self
Pay Patients with a small number of NHS Spot contracts on request frm the local NHS
Board.
% of NHS patients to Ross Hall Business
Row Labels
Sum of cases
NHS
% of cases
5909
9.69%
Private
55063
90.31%
Grand Total
60972
100.00%
BMI Healthcare are registered as a provider with Healthcare Improvement Scotland
(HIS) under the Health & Social Care Act 2008. BMI Ross Hall Hospital is registered as
a location for the following regulated services:•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Termination of Pregnancy
Healthcare Improvement Scotland carried out an unannounced inspection on 7th and 8th
April 2015 and assessed the service against all five quality themes related to the
Healthcare Improvement Scotland (requirements as to independent healthcare
services) regulations and the National Care Standards. Healthcare Improvement
Scotland also considered the Regulatory Support Assessment (RSA) and used this
information when deciding the frequency of inspection and the number of quality
statements inspected.
Based on the findings of this inspection, BMI Ross Hall Hospital was awarded the
following grades:
Quality Theme 0 – Quality of information: 5 - Very good
Quality Theme 1 – Quality of care and support: 5 - Very good
Quality Theme 2 – Quality of environment: 4 - Good
Quality Theme 3 – Quality of staffing: 5 - Very good
Quality Theme 4 – Quality of management and leadership: 5 - Very good
Ross 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
multidisciplinary group and the Medical Advisory Committee.
Regional Clinical Quality Assurance Groups monitor and analyses trends and ensure
that the quality improvements are operationalised. There has been development of
information sharing and best practice.
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 in line with reporting requirements
for Healthcare Improvement Scotland, Health Protection Scotland and Insurers
BMI is a founding member of the Private Healthcare Information Network (PHIN) UK –
as a Scottish site we do not currently contribute to this initiative as it is not recognised
by HIS.The BMI Ross Hall 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 Director of Infection Prevention and
Control and Group Head of Infection Prevention and Control, in
liaison with the Infection Prevention and Control Lead for Ross Hall Hospital
We have had: -
•
MRSA bacteraemia
cases/100,000 bed days
•
MSSA bacteraemia cases
/100,000 bed days
•
E.coli bacteraemia cases/
100,000 bed days
•
cases of hospital
apportioned Clostridium
difficile in the last 12 months.
0.000
11.338
10.187
0
SSI data is also collected and submitted to Health Protection Scotland for Orthopaedic
surgical procedures. Our rates of infection are;
Orthopaedic Surveillance
01.03.15—31.05.15
Number of hip replacements
96
Number of knee replacements
89
Number and details of infections hip and knee
replacements
0
High Impact Intervention Care bundles have been implemented in clinical areas for Hand
Hygiene, PVC, CAUTI, and clinical areas record their compliance and audit details on a monthly
basis.
BMI Learn offers mandatory training with blended modules that include a face to face practical
session for hand hygiene, aseptic non touch technique and other infection prevention activities.
The site Infection Prevention and Control Link in conjunction with the Practice Education
Facilitator and Regional Trainer offer focused training sessions for newly recruited staff to
ensure appropriate foundations are established within the induction period.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
1.2 Assessment of the Care Environment
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.
Senior Management team participate in Leadership Walk rounds which provide the
opportunity to observe and analyse the clinical areas and provide staff with opportunity
to discuss areas of concerns and provide suggestions for improvement in processes.
The Infection Prevention and Control Lead undertake regular environmental audit of all
clinical areas in conjunction with the ward and housekeeping staff, using the Health
Protection Scotland Quality Improvement Tool. Clinical staff undertake self-audit of
compliance with daily, weekly and monthly cleaning schedules. We have a Patient
Participation Strategy and our Patent Focus Group receive feedback at each meeting
regarding the progress with audit and any upgrades or refurbishments to our clinical
environment.
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, Ross Hall Hospital. BMI Healthcare was
awarded the Best VTE Education Initiative Award category by Lifeblood in February
2013 and were the Runners up in the Best VTE Patient Information category.
We see this as an important initiative to further assure patient safety and care. We audit
our compliance with our requirement to VTE risk assessment every patient who is
admitted to our facility and the results of our audit on this has shown 98% compliance
with the Risk Assessment process. In a bid to improve and maintain these results our
VTE Champion has undertaken additional training and support for staff whilst
undertaking the audit and provides feedback to departments on individual performance,
addressing any shortcomings identified.
Ross 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 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.
PE (Rate per 100 admissions)
0.012
0.010
0.0097
0.0099
0.0090
2009
0.008
2010
2011
0.006
2012
0.004
2013
2014
0.002
0.0000
0.0000
0.0000
2013
2014
2015
2015
0.0000
2012
2011
2010
2009
0.000
2. Effectiveness
2.1 Enhanced Recovery Programme (ERP)
The ERP is about improving patient outcomes and speeding up a patient’s recovery
after surgery. ERP focuses on making sure patients are active participants in their own
recovery and always receive evidence based care at the right time. It is often referred to
as rapid recovery, is a 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
At Ross Hall Hospital we continue to embed the principles of the Enhanced Recovery
Programme with collaborative working with our consultants and physiotherapy team as
well as our nursing teams. Year to date average AVOL for Total Hip Replacements=
3.6d NHS and 4.1d PMI; and for Total Knee Replacement 3.9d NHS and 2.8 PMI. Our
corporate Integrated Care Manager analyses and reports site compliance on these
results monthly. Ross Hall has an Enhanced Recovery Programme Group led by the
Director of Nursing and attended by representatives from areas across the hospital. A
current review and revision of Pre-operative Assessment Services and Ambulatory care
is underway to improve service provision and assist in managing patient expectation.
There is a lead physiotherapist for ERP who has initiated local training sessions for staff
to raise awareness and there is a group currently working on patient information
provision.
2.2 Unplanned Readmissions within 31 days and unplanned returns to theatre.
Unplanned readmissions and unplanned returns to theatre are normally due to a clinical
complication related to the original surgery. These are closely monitored and reported
through the internal incident reporting system and investigated accordingly with action
plans formulated in response to lessons learned and Consultants and staff spoken to as
necessary
Unplanned Readmission within 31 days (Rate
per 100 Discharges)
0.060
0.0548
0.0485
0.050
0.040
0.0483
2009
2010
0.0358
0.0282
0.030
2011
2012
0.0178
0.020
2013
0.0099
2014
0.010
2015
2015
2014
2013
2012
2011
2010
2009
0.000
Unplanned return to theatre (Rate per 100
Theatre Cases)
0.0761
0.080
0.070
0.0681
0.0551
0.060
0.0571
0.0554
2009
2010
0.050
0.0403
2011
0.040
2012
0.030
0.0209
2013
0.020
2014
0.010
2015
2015
2014
2013
2012
2011
2010
2009
0.000
Unplanned Returns to theatre and readmission within 31 days are discussed within Clinical
Incident review and Lessons Learned Forms and fed into the Clinical Governance Committee
Recurring themes are analysed and managed appropriately with Consultants meeting with the
Executive Director and Director of Nursing.
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.
Of an Annual response rate of 4723 the patient responses in each category as a %-
Average
Impression of
Admission
Average
Impression
of
Consultant
93.31867462 98.31697734
Average
Impression of
Nursing
95.191769
Average
Impression of
Accomodation
Average
Impression of
Catering
90.702278 91.0527499
Average
Impression
of
Discharge
Average
Impression
of Quality
of Care
Average of
How likely to
recommend
to Friends
and Family
88.32354
98.9732
82
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey
BMI Ross 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.
The main themes of complaints are around billing issues, communication and managing
patient expectation and environmental issues related to the fabric of the estate. Our
Patient Services Department work closely with the hosptial teams to provide support.
Our Patient Services Laision officer visits patients within the ward to receove direct
feedback on performace and what we can learn from patient experience and this has
had positive benefit in faciitating early ressolution and prevention of escalation to the
formal stage.
At any time service users can contact Healthcare Improvement Scotland at Gyle Square
I South Gyle Crescent Edinburgh EH12 9EB
Tel no . 0131 623 4300
The graph above evidences the decrease in number of written complaints received by
Ross Hall Hospital in recent years.. In undertaking investigation of and response to
complaints we ensure that we can demonstrate lessons are learned and action plans
agreed to demonstrate our commitment to continuous quality improvement. Our
‘Lessons Learned session’ are attended by departments across the hospital and staff
can gain insight and engage in valuable learning from incidents in a bid to reduce
recurrence in the future. Lessons learned from other sites and facilities will enhance
this learning experience.
4. Non-Mandatory Quality Indicators
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. Action Plans Reflective Accounts and statements are uploaded to the
system as evidence of ‘closing the loop’. 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.
Our Pharmacy Department participate in a full suite of audit activities looking at
antimicrobial prescribing, prophylaxis prescribing, missed doses audit, controlled drug
audit, and are supported by the BMI policies and procedures under the supervision of
the Group Chief Clinical Pharmacist
Whilst there appears to be an upward trajectory of incidences this is recognised
as improved reporting and improved data quality and greater interdepartmental
working with an absolute focus on clinical governance and safety.
5. Research
No patients were recruited to take part in research.
6. Priorities for service development and improvement
Cancer Services
The development of Cancer Services is a key stategic driver this fiscal year with
significnat improvments in process across areas of the business. The
organisation has recently achieved the Macmillan Environment Award for the
work undertaken to ensure the environment is conducive to standards of
excellence. Review of the terms of reference to ensure robust Multi Disciplnary
Team Review is undertaken within all key tumour groups continues with the
developent of the Cancer Services Improvement Group.
Critical Care
Critical Care services have been reviewed and the hospital now benefits from 24
hour Tier 2 RMO Intensivist Cover and 24 hour Consultant Anaesthetist
Intensivist cover to ensure standards of critical care are achieved and the
hosptial has a robust system for identifying the deteriorating patient and can
implemtn early intervention.
Capsular Endoscopy
The Capsular Endoscopy Service is now fully implemented with patients
benefiting form this minimally invasive procedure. A Specialist Nurse has been
developed to lead the service and develop service enhancements going forward.