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.
Jill Watts, Group Chief Executive
BMI SYON CLINIC
BMI Syon Clinic was originally built for the Coty Cosmetic Company in 1932. Following extensive
refurbishment this art deco listed building was transformed into a prestigious state-of –the –art
private clinic complete with the most advanced diagnostic imaging equipment available.
BMI Syon Clinic offers the following services: Urgent Care Centre, Physiotherapy, Consulting
Rooms, GP service, Cardiology Centre, Minor procedure unit, Allergy testing, Health Screening and
Cardio Pulmonary Exercise testing.
BMI Syon Clinic is registered with the CQC to carry out the following services: Doctors consultation
service, Diagnostic and/or screening service, Doctors treatment service and Urgent Care services.
BMI Syon Clinic is an outpatient clinic and we do not have any inpatient beds. Our minor
procedures involve local anesthetic only at present.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Syon Clinic 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 29 January 2013 and found that BMI Syon
Clinic was compliant to the following standards:
Respecting and involving people who use services
Care and welfare of people who use services
Cleanliness and infection control
Requirements relating to workers
Staffing
Complaints
Records
BMI Syon 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. 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 implemented.
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.
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 at BMI Syon Clinic.
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
Syon Clinic.
We have had: • Zero cases of MRSA bacteraemia in the last year (NHS 1.17cases/100,000 bed days).
• Zero cases of MSSA bacteraemia.
• Zero cases of E.coli bacteraemia.
• BMI Syon Clinic has no inpatients therefore has zero cases of hospital apportioned
Clostridium difficile in the last 12 months.
AUDITS are carried out according to the hospital infection control program and the results
are as follows:
MONTH:
Infection
Prevention
and Control Environmental
Audit
DEC
JAN
FEB
MAR
APR
MAY
JUN
80%
88%
94%
100%
85%
100%
0%
Results by month and Action plans:
DECEMBER 2014
30/12/2015 AUDIT
ACTION PLANS
New RGN appointed as Infection Control Link Nurse. The Nurse is currently undergoing an induction
under the supervision of the Bishopswood Infection Control Nurse. On completion of the induction the
Link infection control nurse will review the items outstanding on the December audit and action.
Part 1: No. 3. SLA with ICD signed on 23 January 2015 – completed.
No. 9 IPC link nurse on supervisory induction – ongoing
Part 3: 1-4 All leaflets were available on site with effect from 16 January 2015 – completed
100% compliant with this audit on 23 January 2015.
_____________________________________________________________________________
JANUARY 2015
26 January 2015
Summary and Action plan: 1. Risk assessment in process of being completed/ CQ/7/6/2015
______________________________________________________________________________
FEBRUARY 2015
20 February 2015
Action:
Part 2:
2. Cleaning Schedule in place as of April 10, 2015 Audit.
Part 3:
8. Single use tourniquet in use as of April 02, 2015.
100% compliant 10 April 2015
MARCH 2015
No actions required (100% score)
APRIL 2015
DATE: 10 April 2014
Action: 3. Lid fully locked onto the bin when discrepancy was noted during the audit. Reinforced
sharps bin training with all staff.
100% compliant with audit as at 10 April 2015
MAY 2015
No actions required.
SUMMARY FOR INFECTION CONTROL:
Apart from the above audits we have a monthly hand hygiene audit. A minimum of 10 staff are
observed washing their hands. This includes the GP’s, RMO’s and the Consultants. Actions from
these audits include removal of jewellery other than wedding bands, being bare below the elbows
and updates on hand washing techniques.
All staff comply with their elearning regarding infection control and undergo a practical Aseptic non
touch technique (ANTT) training and Hand washing training per annum.
During the month of May we have a stand in place at our reception promoting hand hygiene for the
patients and visitors. This includes information on hand hygiene and miniature hand gels samples
for our patients and visitors in order to promote hand hygiene.
We contract out our Cleaning Services and the contracted company is monitored by our link
infection control nurse who undertakes audits of the service provided. The Cleaning company
also audits the cleaning on a monthly basis.
2. Patient experience
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.
How Likely are you to recommend our service to friends and family if they needed similar care or treatment?
Funding Type
Extremel
y likely
Base Size
Likely
Neither likely
nor unlikely
Unlikely
Extremely
unlikely
Don't
Know
Recommend
Not
recommend
All
59
79.7
20.3
0.0
0.0
0.0
0.0
100.0
0.0
Insured &
Self Pay
48
81.3
18.8
0.0
0.0
0.0
0.0
100.0
0.0
NHS
7
How Likely are you to recommend our service to friends and family if they needed similar care or treatment?
Who Seen
Extrem
ely
likely
Base Size
Consultant
(procedure
Consultant
(no procedure)
Likely
Neither
likely nor
unlikely
Unlikely
Extremel
y
unlikely
Don't Know
Recommend
Not
recommend
0
14
78.6
21.4
0.0
0.0
0.0
0.0
100.0
0.0
Nurse
11
63.6
36.4
0.0
0.0
0.0
0.0
100.0
0.0
Diagnostic
Imaging/X-ray
31
87.1
12.9
0.0
0.0
0.0
0.0
100.0
0.0
Physiotherapist
7
Pre Admission
Clinic
0
Other
1
2.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI Syon
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
Stage 3: Patients can refer their complaint to independent adjudication if they are not satisfied with
the outcome at the other 2 stages.
Bmi Syon Clinic is proud to have a low complaints record. The main complaints have been
regarding
• Transparency of pricing – this was actioned by placing notices to inform patients of pricing
and ensuring self paying patients are made aware of the pricing prior to
procedure/consultation/treatment.
• Lift in the car park constantly out of order after rain. As we are a listed building it has taken
some time to get plans passed for a new lift. This lift is scheduled to be replaced 31 July
2015.
• Communication to patients due to delayed clinics, staff have all undergone training re:
customer service and the importance of keeping patients informed of delays. This has
resulted in a significant reduction of complaints in this regards.
3. Priorities for service development and improvement
Development of our services is a key target for Syon Clinic moving forward and we will focus on the
following areas:
GP Services and Primary Care
As we have RMO and GP services at Syon 7 days a week we intend to develop our scope of work
and develop advanced Well Man and Well Woman clinic. This service can be further enhanced by
onward referrals to our team of consultants and / or imaging and diagnostics Centre.
Physiotherapy
We intend to develop our Physiotherapy services by creating a purpose built space and ensuing that
new and innovative equipment in order for our team to offer new services including Gait Scanning
and Vestibular Rehabilitation.
Minor Surgery
Over the next 3 months we hope to have agreement from our parent company to replace the air
exchange unit in our minor surgery room and to have piped gases and suction installed. By doing
this we will be able to extend the range of procedures our consultants are currently offering and to
be able to include conscious sedation.
Patient Journey
As we are a patient centric organisation we ensure patient care is always top of our agenda and so
one of our key drivers is to make our services as easy to access as possible. We have and will
continue to focus on ease of access both in terms of the time the clinic is open and also the physical
attributes of the building. Over the coming months we will extend our opening hours and also replace
our disabled access lift.