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 self-assessment 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.
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Jill Watts, Group Chief Executive
Hospital Information
BMI The Saxon Clinic
The Saxon Clinic has 35 beds with two theatres together with an endoscopy suite / minor theatre,
Imaging department, Physiotherapy, Pharmacy, Cancer Care Service, Health Screening, Travel Clinic,
GP Extra Service and an Outpatients Department with 12 consulting rooms and 2 treatment rooms.
The hospital is supported by caring and professional staff, with dedicated nursing teams and Resident
Medical Officers on duty 24 hours a day, providing care within a comfortable environment. The Saxon
Clinic also provides fertility services as a satellite of Care Fertility Northampton.
Patient bedrooms offer privacy and comfort of en-suite facilities, satellite TV, Wi-Fi and telephone.
There is a rolling programme of bedroom and accommodation refurbishment.
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As well as a private patient service we also offer an NHS Choose & Book programme, which patients
may access via their General Practitioner, allowing them to receive consultation and surgery at BMI
The Saxon Clinic through a contract with Milton Keynes Clinical Commissioning Group (CCG). 33% of
the Clinic’s current work load is NHS.
In the event a patient’s condition urgently requires specialist care BMI The Saxon Clinic cannot provide
there is an SLA agreement in place with Milton Keynes NHS Foundation Trust to transfer the patient
via paramedic ambulance into their care.
Patient facilities are on one level and briefly comprise of:
•
•
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Ward area – 33 beds in single rooms with en-suite facilities.
2 two-bedded rooms with en-suite facilities
Health Screening (Intelligent Health) department and private GP Extra service.
Two operating theatres – one with Lamina flow air controls.
Endoscopy Suite/Minor Theatre 3.
Pharmacy unit providing a service for inpatients and outpatients.
Two imaging rooms providing plain film and fluoroscopy studies and ultrasound. The
department is equipped with digital equipment to provide rapid turnaround voice-recognition
reporting. We have a Fuji PACS workstation which allows image transfer from outside hospitals
through IEP. MRI and CT scanning is provided through an SLA with In Health group.
Physiotherapy department comprises both individual treatment rooms and a gym and an Alter G
treadmill.
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
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BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the Health
& Social Care Act 2008. BMI The Saxon Clinic is registered as a location for the following regulated
services:-
The CQC carried out an unannounced inspection on 01 October 2013 and the results are as follows:
•
Management of medicines
Action needed
People were not always protected against the risks associated with medicines because the
provider had appropriate arrangements in place to manage medicines in Theatres. We have judged that
this has a minor impact on people who use the service, and have told the provider to take action.
•
Supporting workers
Met this standard
The provider was meeting this standard. People were cared for by staff who were supported to deliver
care and treatment safely and to an appropriate standard.
•
Records
Met this standard
The provider was meeting this standard. People were protected from the risks of unsafe
or inappropriate care and treatment because accurate and appropriate records were maintained.
Key to icons
All standards were being met when we inspected the service. If this service has not had a CQC
inspection since it registered with us, our judgement may be based on our assessment of declarations and
evidence supplied by the service.
At least one standard in this area was not being met when we inspected the service and we required
improvements.
At least one standard in this area was not being met when we inspected the service and we have taken
enforcement action.
The CQC have since posted the following statement on their website :
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As part of our planning for the most recent routine inspection, our inspector reviewed the information in
our central database and concluded that no inspection of this standard was required.
BMI The Saxon Clinic 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 through the work of a multidisciplinary group and the Medical Advisory Committee.
Local and Regional Clinical Quality Assurance Groups monitor and analyze trends and ensure that
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.
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.
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 at BMI
The Saxon Clinic.
Infection rates April 14 – March 15
1.1 - Infection Control
► MRSA Bacteraemia
0.000
Rate (per 100,000 Bed Days) of MRSA Bacteraemia Infections at
hospital between Apr 14 - Mar 15
► MSSA Bacteraemia
0.000
Rate (per 100,000 Bed Days) of MRSA Bacteraemia Infections at
hospital between Apr 14 - Mar 15
► E.coli bacteraemia
0.000
Rate (per 100,000 Bed Days) of MRSA Bacteraemia Infections at
hospital between Apr 14 - Mar 15
► C.difficile
0
Number of C.difficile CASES at the hospital between Apr 14 - Mar
15
Audits undertaken at BMI The Saxon Clinic have a narrative summary and action plan where required,
this is distributed to the relevant departments. These are reviewed regularly to ensure actions are
measured, achieved and improvements made where compliance is required. Learning is then shared
and cascaded to teams with the overall aim of improving our patient’s experience of our services.
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SSI data is also collected and submitted to Public Health England on a monthly basis for Orthopaedic
surgical Procedures, which at present include Hip and Knee Arthroplasty’s
The following Infection Prevention Control (IPC) audits have been conducted within the reporting
period:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
World Health Organization (WHO) Hand Hygiene Assessment (January 2015)
Hospital Site self-assessment & associated action plan (January 2015)
Ward Audit -Whole Department (February 2015)
Ward hand hygiene process improvement tool (February 2015)
Theatre Asepsis- Standard Precautions (February 2015)
Theatre Scrub Procedure Surgical (February 2015)
Operating Theatre Asepsis PIT (April 2015)
Catheter Care Bundle Audit- Theatre (Monthly- ongoing)
Urinary Catheter Insertion- Theatre (October 2014)
Peripheral IV Cannula Care Bundle- Theatre (October 2014)
SSI Intra-operative- Theatre (October 2014)
Theatre Hand Hygiene PIT (August 2014)
Mattress and Pillow Audit- Outpatients (February 2015)
Mattress and Pillow Audit- Ward (March 2015)
Imaging PIT standard precautions (May 2014)
Outpatient PIT (September 2014)
Endoscopy Audit (February 2015)
Daniels Healthcare Sharps Audit (November 2014)
There is focused activity with regards to hand hygiene, aseptic non touch technique and other infection
prevention activities. Training for Hand Hygiene (ANTT) is conducted for all staff who work within the
site. This provision is updated regularly as part of the mandatory requirements both through eLearning
and practical sessions and forms part of the clinical competency programme. World Health
Organization (WHO) Five moments training is delivered within the facility and WHO assessments have
been conducted.
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Environmental cleanliness is also an important factor in infection prevention and our patients rate the
cleanliness of our facilities highly as shown in the graphs below
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 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 staff are doing their job.
The results will show how hospitals are performing nationally and locally.
The assessment is measured using a thermometer score encompassing a Pass, Qualified Pass, Fail and
Not applicable grading. Here at The Saxon Clinic we are very proud of our results and they are shown
below
Privacy, Dignity and
Wellbeing
91.89%
Food
Cleanliness
97.53%
96.69%
Condition, Appearance
and Maintenance
92.94%
In 2015 a new thermometer was introduced around Dementia Care and here at The Saxon Clinic we
achieved a score of 90.00%.
drawn from a cohort of previous and current Patients. The day of the Audit was an enjoyable experience with
information gleaned from our assessors.
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The Audit is carried out over a 6 hour period to include all elements of the process with patient assessors being
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 The Saxon Clinic. 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 100% compliance.
VTE audit is conducted on a monthly basis with results being discussed at department meetings and
reported to clinical governance
BMI The Saxon Clinic 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.
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.
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.
Latest results can be found by going on the online SOLAR system provided to you by Quality Health
Page 10
For the current reporting period, the tables below demonstrate that the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing hip
replacement and knee replacement at BMI The Saxon Clinic less than 30 patients went through this
pathway during the time period in question - as a result, no score has been provided.
April 14 – September 14
BMI The Saxon Clinic
England
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
Less
than 30
patients
Less
than 30
patients
Unable to work out health gain as less
than 30 patients went through the
pathway
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
April 14 – September 14
BMI The Saxon Clinic
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
Less
than 30
patients
Less
than 30
patients
Unable to work out health gain as less
than 30 patients went through the
pathway
19.401
36.103
16.702
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
Page 11
We diligently ensure that our NHS patients complete the PROMs questionnaire tool. With the provision
of our Quality Health Solar tool we are now able to draw comparisons of our real time results with other
trusts and providers across the healthcare community. We are able to produce graphs, charts and
tables suitable for reporting back to our staff and clinicians to ensure that learning is shared and where
appropriate improvements can be made.
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 ensuring 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, an 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 co-morbidities,
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
We have developed our ERP by implementing Joint Schools at the pre-assessment stage. This
enhances the patients experience and ensures that expectations are well measured and achieved
throughout their journey. It also draws on expertise from a multidisciplinary team integrated across the
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Our average length of stay, combining all patient demographics, for knee replacement surgery is 2.19
days and for hip replacements this is 2.47, which is very encouraging. We constantly review our top 10
procedures to ensure that patient pathways remain clinically sound with reduced clinical and
operational variances, improving the patient’s experience of our services.
healthcare community including Community Care, Carers and Occupational Therapy to ensure that
support is in place for the patient and their pathway.
Standard activities include but are not limited to discussions around Anatomy / Procedure / Postoperative goals / Expected Length of stay in Hospital and question & answer sessions.
Nurse and Physiotherapy Assessment which includes Informed Consent, being measured for
anti‐embolism stockings, BMI / base line observations, discharge assessment and planning, PROMS,
completion of National Joint Registry (NJR) form, femoral head donation/retrieval consent, patient
Information. Community Occupational Therapy referral is organised as required, expected date of
discharge confirmed, commencement of the setting discharge goals and the provision of further
assessment if a Consultant led anaesthetic review is required.
A full medication history is taken which includes a review of any Anticoagulant Therapy / Advice when
to stop if necessary, Pain Management, Nutritional Support – Carbohydrate Loading/preloading
protocol.
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We have fully implemented the ‘My Roles and My Responsibilities, In Helping to Improve My Recovery’
Leaflets as aids for all NHS Hip and Knee Surgery patients undergoing this pathway. To develop this
initiative further we are looking at implementing material of a similar and appropriate nature for both our
Private Medical Insured (PMI) and Self-pay patients to maintain our current successes with ERP.
2.3 Unplanned Readmissions within 31 days and unplanned returns to theatre.
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Unplanned readmissions and unplanned returns to theatre are normally due to a clinical complication
related to the original surgery.
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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Information from the patient satisfaction survey is discussed at hospital quality forums to ensure
continuous improvement. Individual commendations highlighted in the survey are acknowledged to
staff.
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI The Saxon
Clinic 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
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Stage 3: Patients can refer their complaint to independent adjudication if they are not satisfied with the
outcome at the other 2 stages.
The below table demonstrates the trends of complaints received at BMI The Saxon Clinic for the
2014/15 reporting period. It shows the processes taken in an attempt to satisfactorily resolve patients
concerns and embed the learning from the outcomes into our practice.
Trend
Action taken
Financial: Regarding being charged for
services or charged at a higher rate than
expected.
Full investigations made, integrated across BMI
services and actions taken as appropriate.
Further training arranged as necessary to each case
and learning shared on any recommendations made
to practice improvement.
Services not meeting patient expectations
and requesting re-imbursement.
Full investigations made and actions taken as
appropriate.
Further training arranged as necessary to each case
and learning shared on any recommendations made
to practice improvement.
Full investigations made and actions taken as
appropriate.
Dissatisfaction discussed with the individual
consultant and with the Medical Advisory Committee
(MAC) Chair where appropriate.
These incidents are monitored via Practicing
Privileges and revalidation/appraisals which are
reviewed if there is no improvement.
Learning shared on any recommendations made to
practice improvement
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Patient dissatisfaction with their consultant
CQUINS
The CQUIN framework enables commissioners to reward excellent patient care outcomes. This is done
by linking a proportion of the healthcare provider’s income, from the commissioner, to the outcomes of
the local quality improvement goals.
To demonstrate the achievement of these, BMI Healthcare extracts hospital information corporately
and regionally to send to the commissioners and The Saxon Clinic submits information on a monthly
and quarterly basis then at the end of the year this information is collated to give a yearly achievement.
BMI THE SAXON CLINIC IS PROUD TO SAY THAT WE ACHIEVED
100% CQUINS IN YEAR 14/15
Patient data is kept confidential at all times and only statistics and narrative outcomes are sent to the
commissioners
FRIENDS AND FAMILY TEST: EARLY IMPLEMENTATION –
BMI SAXON
Indicator number
1.2
Indicator name
Friends and Family Test – early
implementation –
All outpatients and Day Case Departments
Indicator weighting
15% of total CQUIN value
(% of CQUIN scheme available)
Description of indicator
Early implementation
Numerator
Not applicable
Denominator
Not applicable
Rationale for inclusion
National CQUIN scheme
FRIENDS AND FAMILY TEST: INCREASED RESPONSE – BMI SAXON
Indicator weighting
(% of CQUIN scheme available)
Description of indicator
Numerator
Denominator
1.3
Friends and Family Test – Increased or
Maintained Response Rate
15% of total CQUIN value
Increased or maintained response rate
Not applicable
Not applicable
Page 19
Indicator number
Indicator name
FRIENDS AND FAMILY TEST: INCREASED RESPONSE RATE FFT –
BMI SAXON
Indicator number
1.4
Indicator name
Friends and Family Test – Increased Response
Rate in acute inpatient and Day-Case services
Indicator weighting
10% of total CQUIN value
(% of CQUIN scheme available)
Description of indicator
Increased response rate
Improving the reporting of medication-related safety incidents –
BMI SAXON
Indicator number
2
Indicator name
Improving the reporting of medication-related safety
incidents
Indicator weighting
10% of total CQUIN value
(% of CQUIN scheme
available)
Description of indicator
Reporting and learning from patient safety incidents
involving medication errors will improve the early detection
of risks and enable actions to reduce harm.
Denominator
Rationale for inclusion
By improving reporting in the short term, the NHS can build
the foundations for driving improvement in the safety of care
received by patients.
At a system level, through high reporting, the whole of the
NHS can learn from the experiences of individual
organisations.
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Numerator
The provider will develop and implement plans which result
in a 20% increase in the number of medication-related
safety incidents
Number of reported medication-related safety incidents in
Q1 - Q4 2014/15
Number of reported medication-related safety incidents in
Q1 - Q4 2013/14
Research shows that organisations which regularly report
more patient safety incidents usually have a stronger
learning culture where patient safety is a high priority.
NHS Safety Thermometer – Data Collection
BMI SAXON
Indicator number
3
Indicator name
NHS Safety Thermometer – Data Collection
Indicator weighting
15% of total CQUIN value
(% of CQUIN scheme available)
Description of indicator
To collect data on the following three elements of the
NHS Safety Thermometer: pressure ulcers, falls and
urinary tract infection in patients with a catheter for all
patients admitted to the provider irrespective of
funding method.
Numerator
Number of months per quarter for which a complete
record of NHS Safety Thermometer survey data
covering all appropriate patients in all appropriate
settings for all relevant measures is submitted
Denominator
Total number of relevant months in the quarter
(usually three)
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PATIENT MOBILISATION
BMI SAXON
Indicator number
4
Indicator name
People with hip and knee surgery are offered a
physiotherapist assessment the day after
surgery and mobilisation at least once a day
unless contraindicated.
Indicator weighting
20% of total CQUIN value
(% of CQUIN scheme available)
Description of indicator
90% of people with hip and knee surgery are
offered a physiotherapist assessment the day
after surgery and mobilisation at least once a
day unless contraindicated.
Numerator
The number of patients with a hip and knee
surgery who are offered a multifactorial risk
assessment to identify and address future falls
risk, and are offered individualised intervention if
appropriate.
Denominator
The number of patients who are eligible
National Clinical Audits
BMI The Saxon Clinic was only eligible to participate in the National Joint Registry audit and all joint
replacements are submitted to this. BMI hospital data is from page 196 onwards in The Natonal Joint
Registry for England, Wales and Northern Ireland 2014. This details surgical data and is updated as
part of the Governments transparency agenda.
We are invited to take part in NCEPOD audits that are applicable to our site, during this period we have
taken part in the NCEPOD sepsis audit.
Her at BMI The Saxon Clinic we have an active and robust clinical audit plan.
1. Research
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No NHS patients were recruited to take part in research.
2. Priorities for service development and improvement
Enhanced Recovery Programme (ERP)
BMI The Saxon Clinic aim to continue to develop ERP at site as part of Local CQUIN indicator 4.0
patient mobilisation. Patients will be offered a multifactorial risk assessment to identify and address
future falls risk, and will continue to be offered individualised intervention where appropriate. All our
patients who undergo hip and knee surgery will continue to be offered a physiotherapist assessment
the day after surgery and mobilisation at least once a day unless contraindicated. This in combination
with an increased focus on our Joint Schools and supplementary carbohydrate loading will ensure the
quality of our service and improve patient rehabilitation and outcomes.
WIWO Lounge
BMI The Saxon Clinic is hoping to develop an ambulatory care lounge for WIWO patients, this will be
used in conjunction with a discharge lounge.
This will be for those patients fit for discharge but unable to make their way home
Medicine Related Safety:
BMI The Saxon Clinic aim to develop and implement plans which result in a 20% increase in the
number of medication-related safety incidents in line with the 14/15 Local CQUIN 2.0 to improve
reporting of medication-related safety incidents. Reporting and learning from these incidents will
improve the early detection of risks and enable actions to reduce harm for all those who use our
services
.
Mandatory Quality Indicators
Unit
Zero
Reporting Periods
(at least last two
reporting periods)
Oct 2012 – Jun 2014
National
Average
Highest National
Score
Lowest National
Score
0.9987
1.1849
0.58345
The BMI The Saxon Clinic considers that this data is as described for the following reasons we have
had no patient mortality during the set period.
Page 23
8.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI The Saxon Clinic for
the reporting period.
BMI The Saxon Clinic will continue to follow best practice guidelines to maintain this score, and so the
quality of its services.
8.2 The BMI The Saxon Clinic patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
Zero
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
At BMI The Saxon Clinic there are less than 30 patients going through the process, therefore meaning that
the site cannot be scored.
Varicose vein surgery
Unit
Zero
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
BMI The Saxon Clinic does not currently submit Patient Reported Outcome Measure Scores (Proms )
for Varicose Vein Surgery
Hip replacement surgery
Unit
Zero
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
21.542
28.6
9.714
Page 24
At BMI The Saxon Clinic there are less than 30 patients going through the process, meaning that the
site cannot be scored.
(ii) Knee replacement surgery during the reporting period.
Unit
Zero
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
At BMI The Saxon Clinic there are less than 30 patients going through the process, meaning that the
site cannot be scored.
8.3
(i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of BMI The Saxon
Clinic within 28 days of being discharged during the reporting period.
Unit
Zero
Reporting Periods
(at least last two
reporting periods)
Apr 11 - Mar 12
National
Average
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
BMI The Saxon Clinic considers this data to be reflective of our continued commitment to deliver a
comprehensive paediatric service that meets the requirements of our younger service users. Paediatric
readmissions’ <28days are admitted to BMI the Saxon Clinic only if sufficient cover is in place from
RSCNs in line with the new corporate policy. If this is not the case there is an SLA
Agreement in place with the local trust to accept paediatric patients as emergency admissions.
BMI The Saxon Clinic is passionate about creating an integrated pathway for our paediatric patients
and their family. This data is as described due to our patient centered approach to delivering care.
We aim to maintain this high standard of responsiveness and will continue to measure its effectiveness
to develop the pathway where appropriate.
Unit
0.20%
Reporting Periods
(at least last two
reporting periods)
Apr 11 – Mar 12
National
Average
Highest National
Score
Lowest National
Score
10.01
14.51
5.54
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The percentage of patients aged 15 or over readmitted to a hospital which forms part of the BMI The
Saxon Clinic within 28 days of being discharged from a hospital which forms part of the hospital during
the reporting period.
BMI The Saxon Clinic considers that this data is extremely positive and is due to the staffs commitment
in ensuring a safe and effective delivery of care throughout the whole of the patient journey.
All of the readmissions <28 days were for known clinical complications following primary surgery where
the appropriate pathway had been followed.
BMI The Saxon Clinic aims to maintain this high standard of care and delivery of a positive experience
for our patients.
8.4
BMI The Saxon Clinic responsiveness to the personal needs of its patients during the reporting period.
Unit
98.24%
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
BMI The Saxon Clinic considers that this data is as described due to our commitment to our patients
and the care that they receive.
BMI The Saxon Clinic has embraced the 6C integrated strategy for improving quality of care and the
patients experience.
Staff have taken ownership of this framework embedding a culture of patient centered care. Intentional
rounding and “Hello my Name is “ have been introduced by the staff to improve our patient outcomes.
We aim to continue to improve on this high standard of responsiveness to patient’s needs, and will
measure where appropriate its effectiveness on any improvement.
8.5
The percentage of patients who were admitted to BMI The Saxon Clinic and who were risk assessed
for venous thromboembolism during the reporting period.
Unit
100%
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Jan 15
National
Average
Highest National
Score
Lowest National
Score
95
100
87
BMI The Saxon Clinic considers that this data is as described from our findings at our clinical audits,
this also demonstrates that there has been no Venous Thromboembolism (VTE) related incidents for
the period April 2014 to January 2015.
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BMI The Saxon Clinic will continue to risk assess all its patients for Venous Thromboembolism and
chart as required on the VTE assessment form.
8.6
The rate per 100,000 bed days of cases of C difficile infection reported within the BMI The Saxon Clinic
amongst patients aged 2 or over during the reporting period.
Unit
Zero
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
14.7
37.1
0
BMI The Saxon Clinic considers that this data is as described for the following reasons, that it has a
stringent infection control policy to report these cases and our auditing procedure has shown we have
no incidences.
At BMI The Saxon Clinic we have in place an SLA with a Consultant Microbiologist who has a
substantive practice within the local NHS trust. Our dedicated team monitors and audits surveillance
data, meeting monthly to assess any underlying trends in line with our patient outcomes. The aim is to
give assurance for the quality of our services. We are very proud of the dedication of our team to the
Infection Prevention and Control (IPC) strategy and aim to maintain this current standard.
8.7
The number and, where available, rate of patient safety incidents reported within BMI The Saxon Clinic
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
292
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
Lowest National
Score
20
139
0
Unit
16.3006
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
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Rate of patient safety incidents reported (Incidents per 100 Bed Days)
Number of patient safety incidents that resulted in severe harm or death
Unit
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
Zero
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
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
0%
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
BMI The Saxon Clinic considers that this data is as described due to our dedication to ensure a safe
environment in which to deliver a high standard of care.
BMI The Saxon Clinic considers this data to be very encouraging and demonstrates both our
commitment to our patients and our intentions to create a safe and effective care pathway.
We aim to maintain this measure by:
•
•
•
Continuing to have in place a robust process for patient safety incident reporting and
management
Continuing to have in place a systematic approach to learning
By continuing to promote a reporting and transparent culture
8.8
Unit
92.31%
Reporting Periods
(at least last two
reporting periods)
2014
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
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The percentage of staff employed by the BMI The Saxon Clinic during the reporting period, who would
recommend the BMI The Saxon Clinic as a provider of care to their family or friends.
Non-Mandatory Quality Indicators
9.1 The percentage of patients who received care as inpatients or discharged from A &E during the
reporting period, who would recommend BMI The Saxon Clinic as a provider of care to their family or
friends.
Unit
82.50%
Reporting Periods
(at least last two
reporting periods)
Jun 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
BMI The Saxon Clinic considers this data is very positive and is above the national average. This is
due to the staff dedication to provide high quality care to our patients.
Despite this we strive to improve on this unit number by improving the response rate to the FFT
questions.
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This will enable us the opportunity to collate a more concise view of how our patients view our services,
and where necessary take the relevant action