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 St Edmunds Hospital has 31 beds with all rooms offering the privacy and comfort of ensuite facilities, satellite TV, wi-fi access and telephone. 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 fire system upgrade has been completed. The uninterrupted power supply system has been
replaced.
The physiotherapy service has now been brought totally in-house which has contributed to
continued patient service improvement and supported our delivery of the enhanced recovery
pathway for hip and knee replacement patients.
NHS work currently accounts for 42% of our overall work. We currently offer orthopaedics,
hernia repairs, cataract surgery, gynaecology, limited colo-rectal and urology services on
Choose and Book. We have continued our AQP contract for West Suffolk Adult Carpel Tunnel
service and have a number of spot NHS contracts for footwork, scope surveillance,
gynaecology, urology, general surgery and orthopaedic work.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI St Edmunds Hospital is registered as a location for the
following regulated services:•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
We are in the process of registering for Family Planning services.
We have commenced the replacement of carpet in patient rooms for hard flooring and have had
3 handwash basins installed in the ward corridors over the last year to improve infection
prevention and control compliance.
The CQC carried out an unannounced inspection on 17th December 2013 and found one
standard not met which was in relation to quality assurance in assessing and monitoring the
quality of service provision covering infection prevention and control, equipment and
maintenance.
Standards of treating people with respect and involving them in their care
Standards of providing care, treatment & support which meets people's needs
Standards of caring for people safely & protecting them from harm
Standards of staffing
Standards of management
Actions were immediately taken to address the areas of concern and BMI St Edmunds were
then deemed compliant after subsequent follow-up unannounced inspection in July 2014.
BMI St Edmunds 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 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.
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 Jill Cerny.
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 St
Edmunds.
We have had: •
No MRSA bacteraemia cases/100,000 bed days
•
No x MSSA bacteraemia cases /100,000 bed days
•
No x E.coli bacteraemia cases/ 100,000 bed days
•
No cases of hospital apportioned Clostridium difficile in the last 12 months.
•
SSI data is also collected and submitted to Public Health England for Orthopaedic
surgical procedures. We have had no hip or knee replacements infections we are
aware of over the last year.
o Hips replacements
o Knees replacements
The site undertakes High impact intervention care bundle audits for peripheral cannulas,
surgical site pre and post op, urinary catheters insertion and ongoing care.
Actions are taken to improve and maintain compliance and results are fed back at Infection
Prevention and Control meetings, Clinical Governance meetings and Medical Advisory
Committee meetings.
High Impact
Interventions
2014-2015
Monthly
Surgical site pre
op
Surgical site
post op
Urinary
catheter
insertion
Urinary
catheter
ongoing care
Peripheral line
insertion
Peripheral line
ongoing care
CVC insertion
CVC ongoing
care
Blood Cultures
Hand Hygiene
BBE
Clinical
area
responsible
for audit
Oct
Nov
Dec
Jan
Feb
Theatre
100%
100%
100%
100%
100%
77%
Ward
100%
100%
100%
100%
100%
100%
Theatre
100%
100%
100%
100%
100%
100%
Ward
100%
100%
88%
100%
100%
100%
Theatre
91%
92%
83%
91%
96%
96%
Ward
100%
100%
100%
100%
100%
95%
Theatre
N/A
N/A
N/A
N/A
N/A
N/A
Ward
RMO
All staff
All staff
N/A
N/A
100%
N/A
N/A
100%
N/A
N/A
100%
N/A
N/A
90%
N/A
100%
100%
N/A
N/A
100%
Annually
HCAI Self
Assessment
Clinical Areas
Inpatient
management
OPD
management
Patient
Equipment
PPE
Sharps safety
Mattresses
Endoscopy
Pharmacy
Theatre
March
IPC
IPC
98%
IPC
95%
IPC
IPC
IPC
IPC
IPC
Theatre
Pharmacy
IPC
100%
100%
100%
100%
Peripheral line insertion has been a main area for focus as a result of the audits and this has
largely been due to medical staff not always wearing gloves for cannulation. This has been
raised at MAC.
We have launched Asceptic Non-touch Training with the staff this year from September
onwards through a theoretical e:learning module and competency assessment.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
Excellent & Very good
100%
80%
60%
Excellent & Very good
40%
20%
0%
Room cleanliness
Bathroom
cleanliness
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.
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
March 2014 audit, published by NHS England, August 2014 are shown below.
Actions taken as a result of the audit included:
• the removal of pallets left outside the waste compound
• repairs to the road where it had become eroded
• remarking of the pedestrian path alongside the road
• signage to mark the drop off point at the Hospital Reception
• reception radiator cleaning increased to bi-monthly due to their position by the entrance
• replacement flooring to reception toilets
• removal of limescale residue around some taps and increased audit checks of these
areas.
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 St Edmunds 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 BMI St Edmunds achieving 100% of
patients being risk assessed. The VTE Risk Assessment has been incorporated into the patient
medication chart so is reviewed by nursing staff frequently.
BMI St Edmunds 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.
In 2014-15 we had not reported incidences of DVT at this site.
DVT (Rate per 100 admissions)
0.045
0.040
0.0396
0.0346
0.035
0.0343
2009
0.030
2010
0.025
2011
0.020
2012
0.015
2013
0.010
2014
2015
2011
0.0000
0.0000
2015
0.0000
2014
0.0000
2010
0.005
2013
2012
2009
0.000
In 2014-15 we had only one pulmonary embolism which was notified to us post patient discharge.
PE (Rate per 100 admissions)
0.0686
2009
2010
0.0396
0.0357
0.0354
2011
2012
2013
2014
2015
2014
0.0000
2013
2012
0.0000
2011
2010
0.0000
2009
0.080
0.070
0.060
0.050
0.040
0.030
0.020
0.010
0.000
2015
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.
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 St Edmunds Hospital. Due to the reporting
mechanism for PROMS results are only reported where there are more than 30 PROMs
questionnaire returns a quarter. We are therefore only able to report hip scores.
April 14 – September 14
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
BMI St Edmunds Hospital
23.222
39.556
16.333
England
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
April 14 – September 14
BMI St Edmunds Hospital
England
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
<30
unable
to score
<30
unable
to score
Unable to score
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: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
We are pre-assessing the majority of patients planned for general anaesthesia and additionally
are telephone pre-assessing many patients undergoing procedures under local anaesthesia.
We have introduced group education classes for hip and knee joint surgery patients which have
proved very popular from patient feedback.
We are reviewing our service to see if this workshop approach could work for any of our other
specialities.
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.
Unplanned readmission with 31 days per 100 discharges, have remained low.
Unplanned Readmission within 31 days (Rate per
100 Discharges)
0.4635
0.500
2009
0.400
2010
0.300
0.1981
2011
0.2300
0.1731
0.200
0.1373
2012
0.1429
2013
0.100
0.0000
2015
2014
2013
2012
2011
2010
2009
0.000
2014
2015
Unplanned return to theatre (Rate per 100
Theatre Cases)
0.4545
0.500
0.4197
2009
0.400
2010
0.300
0.200
0.2592
0.2221
0.1533
2011
2012
0.1128
2013
0.100
0.0000
2014
2015
2014
2013
2012
2011
2010
2009
0.000
2015
Unplanned return to theatre cases have remained consistently low.
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. Additionally we participate in data collection questionniare for NHS Friends and Family for
both in-patient and outpatient servcies.
Do tables with your data and narrative on your improvement plans etc.
Suggest doing the scores of % excellent and very good for the grouped sectios i.e. Admisison,
Nursing, Accommodation, Catering, Departure, Overall quality of care. Compare last 2 years.
2012-14
2014-15
98
Admission
96
100
Admission
80
Consultant
Nursing
94
60
Nursing
Accommodation
40
Accomodation
Catering
20
Catering
92
90
88
86
0
Departure
84
2012/2013
Discharge
St Edmunds Hospital 201415
2013/2014
Quality of Care
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI St
Edmunds 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.
BMI St Edmunds
Written Complaints (Rate per 100 admissions)
0.900
0.7961
0.800
0.700
0.7431
0.6786
0.6337
2009
0.5704
0.600
0.5258
2010
0.4804
0.500
2011
0.400
2012
0.300
2013
0.200
2014
2015
0.100
2015
2014
2013
2012
2011
2010
2009
0.000
We have received 1 written complaint regarding patient care and 3 verbal complaints from NHS
patients over the last year. No trends were identified.
Across the site we received a total of 23 complaints April 2014 to March 2015:
Type of
complaint
Total
Number
Clinical
Consultant
Admin
Financial
Other
Verbal
14
6
4
4
0
0
Written
9
5
0
1
3
0
Total
23
11
4
5
3
The number of complaints represents a 0.0003% complaint rate across the site for in and
outpatient care. There were no trends in the data.
Actions taken as a result of feedback:
•
•
•
Customer care training rolled out to all staff with patient contact
Changes to processes in our admissions team
Pain training to be refreshed for clinical team
4. CQUINS
CQUINs were agreed and set to cover:
•
•
•
•
•
Number of Friends & Family responses
Collection of Outpatient Friends & Family Response impelementation
High impact intervention care bundle completion for patients with an indwelling urinary
catheter
Dementia assessments on inpatients over the age of 65years
Smoking cessation health education literature and cessation referrals if required for
patients identified as a smoker at pre-assessment
Friends & Family questionnaire returns dropped off in the last quarter. On investigation it was
discovered that some inpatients were being given the outpatient questionnaire for completion
and that this was affecting our data. The questionnaires have now been altered to clearly
identify them as ‘in-patient’ or ‘out-patient’ so this should address the problem going forward.
BMI St Edmunds has achieved the CQUINs set across all the areas for this year.
CQUINs 14-15 BMI Bury St Edmunds Hospital
N1a
Friends and Family Increased Response
Rate
Description of Indicator
Increase response rate
Performance and Target
25% in Q1, 26% in Q2, 27% in Q3
and 28% in Q4
N1b
54.4
25%
Yes
40.1
26%
Yes
na
na
na
na
na
na
Implem
ent
only no
na
100%
70%
Yes
Implem
entatio
n only no
value
na
93%
tbc
na
Implem
entatio
100% n only no
value
55
27%
Yes
32.12
28%
Yes
Imple
ment
and
Yes
na
na
na
100%
70%
yes
100%
96%
tbc
100%
tbc
100%
tbc
100%
tbc
Friends and Family Early Implementation
Extended implementation of FFT to
Description of Indicator Outpatients and Daycases by October
2014
Report implementation to commissioner
Performance and Target
by 31 Oct 2014
N2.1
%
%
%
%
Achiev
Achiev
Targ Achieve
Targ Achiev
Achieve Target
Achiev Target
Achieve
Achieve
ed
ed
et
d
et
ed
ment
ement
ment
ment
Safety Thermometer - Improvement Goal
Description of Indicator
Catheter Care Bundle Audit
Percentage of patients with appropriate
Performance and Target bundle (implement Q1, 70% Q2 and 100%
Q3, Q4 target tbc)
L1
Description of Indicator
Mental Capacity
Assessing inpatients aged 65 or over
using the agreed questionnaire
Percentage of inpatients aged 65 or
over who were asked the agreed
Performance and Target questions (Implementation Q1, target to 50%
be set thereafter for subsequent
quarters achievement)
L2
Description of Indicator
70% 100%
Smoking Cessation
Offering advice on quitting to patients
who are identified as smokers at preoperative assessment clinics
Percentage of smokers who were
Implem
provided with self-help and selfentatio
Performance and Target referral information (Implementation Q1 100% n only and Q2, targets to be set for Q3 and
no
Q4.
value
na
5. National Clinical Audits
BMI St Edmunds Hospital was only eligible to participate in National Joint Registry audit and all
joint replacements are submitted to this. BMI hospital data is from page 196 onwards in
attached latest NJR report.
Quality of information submitted by BMI St Edmunds Hospital. .
Data for 1 April 2013 - 31 March 2014
This
National
Hospital Expected
Quality Measure
Compliance (For the
Trust)
Consent
No Data Available
Better Than
-
-
99.4%
85.0%
93.7%
92.0%
8 Days
30 Days
Expected
Valid NHS number
Time taken to enter data
As Expected
Better Than
Expected
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
•
•
•
•
•
•
•
Access road badly eroded in places after the winter and unable to be repaired. To be resurfaced to prevent risk of falls to our patients and visitors.
High toilet to be put into Reception area toilet to assist patients with arthritic hips. This
was as a result of patient focus group feedback.
Improved internal signage as identified at PLACE audit to identify toilets in Reception
and way out signage from pre-assessment
Pre-assessment screening to be undertaken for all local anaesthetic procedures as well
as general anaesthetic procedures.
Meal courses to be served separately at meal times as identified at PLACE audit.
Redecoration of some patient rooms to be undertaken to refreshen.
Recovery monitors to be replaced to increase monitoring provision.
•
Feedback of incidents with actions to the relevant departments for improved shared
learning.
8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI St Edmunds
Hospital for the reporting period.
Unit
Reporting Periods
(at least last two
reporting periods)
Oct 2012 – Jun 2014
0.00
National
Average
Highest National
Score
Lowest National
Score
0.9987
1.1849
0.58345
BMI St Edmunds Hospital does not have a High dependency unit or intensive care and has only
undertaken day case chemotherapy. No patient deaths have been reported.
8.2 The BMI St Edmunds Hospital patient reported outcome measures scores for
(i)
Groin hernia surgery
Unit
Not reported
due to low
numbers.
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
(ii)
Varicose vein surgery for NHs patients is not undertaken at this site.
(iii)
Hip replacement surgery
Unit
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
16.333
National
Average
Highest National
Score
Lowest National
Score
21.542
28.6
9.714
The BMI St Edmunds Hospital has an active enhanced recovery programme in place and a hip
pathway. Joint school classes have been commenced to improve patient preparation and
expectation.
(iv)
Unit
17.04
Knee replacement surgery during the reporting period.
Reporting Periods
(at least last two
reporting periods)
April 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
16.641
24.429
5.833
Hospital data unavailable for period as for hip surgery previous quarter data displayed.
The Hospital considers that this data is as described due to the active enhanced recovery
programme and joint school for knee surgery patients.
8.3 (i) This site does not admit children under the age of 18 years of age.
8.4 The BMI St Edmunds responsiveness to the personal needs of its patients during the
reporting period.
Unit
98.19%
Reporting Periods
(at least last two
reporting periods)
2014-2015
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
This result was obtained from the average of all measures combined (Impression of
admission/consultant/Nursing/Accommodation/ Catering/Discharge/Quality of Care/How likely to
recommend to Friends and Family).
Monthly quality meetings are held to feedback patient results and review actions to be taken to
improve the patient journey and experience.
8.5 The percentage of patients who were admitted to BMI St Edmunds Hosptial) 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
The BMI St Edmunds considers that this data is as described for the following reasons:
consistent adherence to completion of pathway. The VTE scores were embedded into the
patient medication charts which ensures consistent completion by the nursing staff.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the St
Edmunds Hospital amongst patients aged 2 or over during the reporting period.
Unit
0.00
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
The Hospital only admits over 18 years of age.
8.7 The number and, where available, rate of patient safety incidents reported within the BMI St
Edmunds 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
86
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Mar 15
National
Average
Highest National
Score
Lowest National
Score
20
139
0
Rate of patient safety incidents reported (Incidents per 100 Bed Days)
Unit
6.6755
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Mar 15
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
1
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Mar 15
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
0.08%
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Mar 15
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
The number of incidents and rate of incidents per 100 bed days reported appears high but
demonstrates the robust reporting culture across site. Comparatively the number of incidents
resulting in severe harm was very low.
The BMI St Edmunds Hospital considers that this data is as described for the following reasons:
• Work has been undertaken to improve the reporting of incidents and near miss events
across the departments and the importance of reporting so incidents can be reviewed
and actions taken.
• Improved clinical training programme for staff
• We are in the process of training all clinical leads how to report incidents on the system
We will continue to encourage this open reporting culture.
9. Non-Mandatory Quality Indicators
9.1 The percentage of patients who received care as inpatients during the reporting period, who
would recommend the BMI St Edmunds Hospital as a provider of care to their family or friends.
Unit
82.42%
Reporting Periods
(at least last two
reporting periods)
April 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
The following actions have been taken to improve this:
• To try and increase the number of responses returned
• Minimum 6 weekly quality review meetings to discuss results and comments
• Quality Health results to be a mandatory topic for discussion at all departmental
meetings