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
1
BMI The Sloane Hospital
BMI The Sloane Hospital in Beckenham, Kent and 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 and
medical procedures together with friendly, professional care.
The Sloane Hospital has a state of the art diagnostic imaging department and a pro-active
physiotherapy department. Our Consulting rooms are modern and well equipped including a
nurse led pre admissions service.
The Sloane Hospital has 32 beds with rooms offering the privacy and comfort of en-suite
facilities, freeview, Wi Fi and a telephone in every patient room.
The hospital has two theatres (one with laminar flow) and can provide level two High
Dependency care.
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. The majority of surgical specialties are accommodated at The Sloane,
including neuro surgery, orthopaedics, cosmetic surgery, gynaecology, general surgery,
gastroenterology, ENT surgery, vascular surgery, and Ophthalmology.
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. An emergency medical admissions
service is available 24 hours a day supported by leading medical physicians.
The Sloane Hospital is engaged in providing some NHS Standard Contract Choose and Book
service cover, with published offerings in Trauma and Orthopaedic, Neurosurgery and pain
management services. The hospital also engages in a variety of periodical contract work
with local NHS Trusts. NHS work currently accounts for around 5 % of the Sloane Hospitals
activity.
2
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under
the Health & Social Care Act 2008. BMI The Sloane is registered as a location for the
following regulated services:•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
During previous year, the carpet in Ground floor ward was removed and replaced with
laminate flooring to meet IPC guidelines. All patient rooms on this floor was repainted and
interior furnishings updated at the same time.
Flooring in both anesthetic, theatres 2 and recovery, was upgraded.
2 bedpan macerators installed for both wards.
The CQC carried out an unannounced inspection on 21st November 2013.
Date of Inspection: 21/11/13 Date of Publication: 7/01/14
Respecting and involving people who use Services: Met this standard
Care and welfare of people who use services: Met this standard
Safeguarding people who use services from Abuse: Met this standard
Supporting workers: Met this standard
Assessing and monitoring the quality of service Provision: Met this standard
BMI The Sloane 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.
3
Regional Clinical Quality Assurance Groups monitor and analyses trends and ensure that the
quality improvements are operationalised.
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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1. Safety
1.1 Infection prevention and control
The focus on infection prevention and control continues under
the leadership of the Group Head of Infection Prevention and
Control, in liaison with the link nurse in BMI The Sloane
Hospital.
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 BMI The Sloane Hospital.
We have had: • No MRSA bacteraemia cases/100,000 bed days
• No MSSA bacteraemia cases /100,000 bed days
• One E.coli bacteraemia cases/ 100,000 bed days
• No cases of hospital apportioned Clostridium difficile in the last 12 months or in the
rolling last six years.
• SSI data is also collected and submitted to Public Health England for Orthopaedic
surgical procedures.
• Our rates of infection are;
o None :Hips
o None: Knees
5
The Sloane Hospital uses care bundles as a means of documenting interventions in for
example the following areas :
• Surgical site care
• Urinary catheter care
• Intravenous peripheral lines
• Surgical site infections.
These interventions are audited by departmental infection control links, infection control
audits are completed monthly as part of a rolling corporate program, with different themes
each month, for example Sharps management, Surveillance, waste management, isolation
facilities and equipment cleansing with compliance averaging 92%.
All clinical staff undergo annual mandatory training and practical competency based
assessment in ANTT (Aseptic non touch Technique) for clinical intervention.
Environmental cleanliness is also an important factor in infection prevention and our
patients rate the cleanliness of our facilities highly.
1.2 Patient Led Assessment of the Care Environment (PLACE)
We believe a patient should be cared for with compassion and dignity in a clean, safe
environment. Where standards fall short, they should be able to draw it to the attention of
managers and hold the service to account. PLACE assessments will provide motivation for
improvement by providing a clear message, directly from patients, about how the
environment or services might be enhanced.
In 2013 we introduced PLACE, which is the new system for assessing the quality of the
patient environment, replacing the old Patient Environment Action Team (PEAT)
inspections.
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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.
Results of the hospital for 2014 were:
PRIVACY
DIGNITY
FOOD AND AND
CLEANLINESS HYDRATION WELLBEING
CONDITION
APEARANCE
AND
MAINTENANCE
Site score
2014
99.63%
96.93%
71.25%
96.12%
National
average
97.25%
88.79%
87.73%
91.97%
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 Sloane 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 a twelve month average of 100%
this is maintained through robust orientation of new staff, regular audit of practice by all
members of the ward team and annual re fresher training on VTE prophylaxis and
awareness.
The Sloane 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. We have no incidents of VTE for the period between April
2014 and March 2015.
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2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Patient Reported Outcome Measures (PROMs) are a means of collecting information on the
effectiveness of care delivered to NHS patients as perceived by the patients themselves.
PROMs is a Department of Health led programme.
Latest results can be found by going on the online SOLAR system provided to you by Quality
Health
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 The Sloane Hospital. The Sloane
Hospital participates in data collection, however has Insufficient numbers (less than 30) to
generate reportable data.
April 14 – September 14
The Sloane Hospital
England
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
/
/
Insufficient numbers to produce data.
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
April 14 – September 14
The Sloane Hospital
England
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
/
/
Insufficient numbers to produce data
19.401
36.103
16.702
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
2.2 Enhanced Recovery Programme (ERP)
The ERP is about improving patient outcomes and speeding up a patient’s recovery after
surgery. ERP focuses on making sure patients are active participants in their own recovery
and always receive evidence based care at the right time. It is often referred to as rapid
recovery, is a new, evidence-based model of care that creates fitter patients who recover
faster from major surgery. It is the modern way for treating patients where day surgery is
not appropriate.
ERP is based on the following principles:-
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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
9
Our Hospital ERP committee is in place and meets through the patient journey team.
Carbohydrate loading drinks have been introduced earlier this year. We have a regular
review of our ERP data through our clinical governance team and HODs meetings. We are
looking at ways to introduce joint schools for our patients by working with teams at other
BMI sites within our cluster.
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.
10
Unplanned re admission count for BMI The Sloane.
We have had minimal patients resulting in an unplanned re admitted , in comparison to
other sites in our group (group D) we look slightly higher for one month, however in reality
the biggest number was only two patients in May 2014.
Our return to theatre count is most often below the average for our site group (D) with two
peeks however of only two patients.
11
The Sloane Hospitals return to theatre count.
12
Any trends or concerns would be investigated via our Clinical Governance committee and
discussed further at our management Team meeting and Medical advisory meeting.
13
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.
Sloane
4567
94%
98%
95% 94%
94%
94%
88%
98%
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2013/2014 Quality Data
Overall impression of the arrival process: has continued throughout the year, with a
significant improvement matching BMIs avaerage in the last few months.
Overall impression of nursing care: has consitently improved since 2013 and is maintianing pace
with BMI average for current date which has also improved.
14
Overall impression of accommodation: following focused attention by the patient journey team has
move up 10% to current date.
15
Overall impression of catering: is consistency strong and well above BMI average.
Overall Quality of care : Has demonstrated a stong consistent trend from 2013 through to current
date.
16
Quality for our patients is constitently high in our focus and attentions, for many areas we exceed all
of BMI, and for others we target our efforts.
To support engagement and improvement in improving our quality Health results The
Sloane Hospital holds alternate monthly Pain meetings and patient journey meetings. These
are minuted meetings with focused action plans and have members from across the multi
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disciplinary team both clinical and non clinical. The Sloane hospitals excellent overall
average of nursing care score of 97% and Quality of care score of 97% for example
demonstrates the effectiveness off our inhouse training and culture of our teams.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey
BMI The Sloane 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.
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The Sloane Hospital written complaint count and constistently reduced over the last year.
In comparitive to other sites in our group we are often below the average number with the
majority not being upeld.
Those that are upheld have been resolved at stage one and not escalated.
Through use of the data available we are able to focus on our most common themes and
issues, these are taken to our patient journey team, Governance team and Head of
department meetings.
The sites most common
complaint:
Communication/information to
patients (written and oral)
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4. CQUINS
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5. National Clinical Audits
BMI The Sloane Hospital was only eligible to participate in National Joint Registry audit and
all joint replacements are submitted to this.
2014 data
The Sloane Hospital has an excellent consent rate 90% in 2014 and 100% year to date.
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6. Research
No NHS patients were recruited to take part in research.
22
7. Priorities for service development and improvement
Development of liver services
Development of improved ambulatory care services
Development of 5 day rule
Increase pre admission clinics and review timing of service
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8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI The
Sloane Hospital for the reporting period.
Unit
437*
0
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 Sloane Hospital considers that this data is as described for the following reasons, there
were no incidents to report.
8.2 The Sloane Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
437 *
o
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
The Sloane Hospital considers that this data is as described for the following reasons * =
less than 30 patients going through the process, meaning that the site cannot be scored.
(ii) Varicose vein surgery
Unit
0
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 Sloane Hospital considers that this data is as described for the following reasons * =
less than 30 patients going through the process, meaning that the site cannot be scored.
(iii) Hip replacement surgery
Unit
0
Number
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
The Sloane Hospital considers that this data is as described for the following reasons * =
less than 30 patients going through the process, meaning that the site cannot be scored.
(iv) Knee replacement surgery during the reporting period.
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Unit
0
Number
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
The Sloane Hospital considers that this data is as described for the following reasons * =
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 the
Sloane 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
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
The Sloane Hospital considers that this data is as described for the following
reasons: patients aged 0-14 are not admitted to the Sloane.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part
of the Sloane Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
0.15 %
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
The Sloane Hospital considers that this data is as described for the following reasons only a
small number of patients were readmitted.
8.4 The Sloane Hospitals responsiveness to the personal needs of its patients during the
reporting period.
Unit
94.24 %
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
The Sloane Hospital considers that this data is as described for the following reasons only
going focus on quality patient care and experience.
8.5 The percentage of patients who were admitted to The Sloane Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
25
Reporting Periods
National
Highest National
Lowest National
100%
(at least last two
reporting periods)
Apr 14 – Jan 15
Average
Score
Score
95
100
87
The Sloane Hospital considers that this data is as described for the following reasons regular
staff training and robust orientation keeps our compliance high for risk assessments.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Sloane
Hospital amongst patients aged 2 or over during the reporting period.
Unit
0 Rate
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
8.7 The number and, where available, rate of patient safety incidents reported within the
Sloane 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
Unit
185
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sep 14
National
Average
Highest National
Score
Lowest National
Score
20
139
0
Rate of patient safety incidents reported (Incidents per 100 Bed Days)
Unit
7.7731%
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
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
40.2
97
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per
100 Admissions)
Unit
0%
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Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
The Sloane Hospital considers that this data is as described for the following reasons:
positive reporting is promoted with a long standing consistent approach in reporting for
example a day case to an overnight stay as an adverse incident not consistent at all other
sites.
8.8 The percentage of staff employed by the Sloane Hospital during the reporting period,
who would recommend the Sloane Hospital as a provider of care to their family or friends.
Unit
77 %
Reporting Periods
(at least last two
reporting periods)
2014
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
The Sloane Hospital considers that this data is as described for the following we have a
committed and loyal work force who recognize the standards and quality of care delivered at
the Sloane.
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9. 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 the Sloane Hospital as a provider of care
to their family or friends.
Unit
77%
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
The Sloane Hospital considers that this data is as described for the following reasons we
have a large number of regular patients who are reluctant to repeat completing
questionnaires such as friends and family therefore our returns are sometimes disappointing.
The Sloane Hospital is continuing to promote patients response to improve this percentage,
and so the quality of its services, by gaining a better overview of recommendation.
………………………………….
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