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
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BMI Three Shires Hospital
The hospital has 3 Theatres together with an Endoscopy suite, Minor operations theatre,
Imaging department, Physiotherapy, Pharmacy, Oncology Service, Health Screening, GP Extra
Service and an Outpatients department with 12 consulting 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 responsive and comfortable environment.
There is a planned programme of refurbishment for summer 2015 that will see our bedroom and
bathroom facilities renovated. All our bedrooms do and will continue to offer privacy and comfort
of en-suite facilities, satellite TV, Wi-Fi and telephone.
As well as a private patient and medically insured service we also offer an NHS Choose & Book
referral programme, which patients may access via their General Practitioner. This enables
them to receive consultation and surgery at BMI Three Shires Hospital through a contract with
Nene Clinical Commissioning Group (CCG) and Circle Services 43% of our current work load is
NHS.
In the event a patient’s condition urgently requires specialist care that BMI Three Shires
Hospital cannot provide there is an SLA agreement in place with Northampton NHS Foundation
Trust to transfer the patient via paramedic ambulance into their care.
Patient facilities are across two levels and briefly comprise of:
•
•
•
•
•
•
•
Ward area – 46 beds in single rooms with en-suite facilities.
Day unit comprising of 5 beds.
Private GP service.
3 operating theatres – two with Lamina flow air controls.
Endoscopy Suite/Minor ops Theatre.
Pharmacy unit providing a service for inpatients and outpatients.
Imaging Service- Consisting of:
o General Radiography-including all Plain Film, Leg length Measurements, Full
Spine Imaging, IVU’s & Colon Transit Studies.
o Fluoroscopy-including GI tract Imaging & Arthrograms.
o MRI-including MRCP, MR Arthrography, MR Head & Neck Angiography.
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o
o
o
•
Ultrasound-including Abdomen, Pelvis, Thyroid, Testes, Soft Tissue & Vascular,
and Musculoskeletal Ultrasound.
Interventional MSK Ultrasound-including Aspiration, Dry Needling & Therapeutic
Injections.
Business case submitted for CT facilities.
Physiotherapy department comprises both individual treatment rooms and a gym.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Three Shires Hospital is registered as a location for the
following regulated services:•
•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Termination of Pregnancy
Family Planning
The CQC carried out an unannounced inspection on 17th September 2013 and found
Standards of consent to care and treatment
Standards of care and welfare of people who use service
Standards of supporting workers
Standards of assessing and monitoring the quality of service
Standards of records
Three Shires Hospital has a local framework through which clinical effectiveness, clinical
incidents and clinical quality is monitored and analysed. Where appropriate, action is taken to
continuously improve the quality of care. This is through the work of a multidisciplinary group
and the Medical Advisory Committee.
Regional Clinical Quality Assurance Groups monitor and analyse trends and ensure that the
quality improvements are operationalised. There has been development of
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.
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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
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 Three Shires Hospital
We have had: •
Zero- MRSA bacteremia cases/100,000 bed days
• Zero- MSSA bacteremia cases /100,000 bed days
• Zero- E.coli bacteremia cases/ 100,000 bed days
• Zero number -of hospital apportioned Clostridium
difficile in the last 12 months.
• SSI data is also collected and submitted to Public
Health England for Orthopedic surgical procedures. Our rates of infection are;
o Hips
o Knees
Any audit undertaken at BMI Three Shires Hospital has a narrative summary and action plan
where required, which 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.
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
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Health Organisation (WHO) Five moments training is delivered within the facility and WHO
assessments have been conducted.
IPC audits are carried out here at BMI Three Shires Hospital in a continued commitment to our
infection prevention processes and our patient’s needs and these include but are not limited to:
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•
•
•
•
•
•
•
•
•
•
•
•
World Health Organisation (WHO) Hand Hygiene Assessment
Hospital Site self-assessment & associated action plan
Theatre Asepsis- Standard Precautions
Operating Theatre Asepsis PIT
Central Venous Catheter- Theatre
Catheter Care Bundle Audit- Theatre
Peripheral IV Cannula Care Bundle- Theatre
SSI Intra-operative- Theatre
Theatre Hand Hygiene PIT
Mattress and Pillow Audit- Outpatients
Mattress and Pillow Audit- Ward
Daniels Healthcare Sharps Audit
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
The graphs below demonstrate how our patients valued both our Room and Bathroom
Cleanliness during their care pathway. Over 90% of our service users consistently found our
facilities either ‘very good’ or 'excellent.’
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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.
Dementia
Food
Condition, Appearance
and Maintenance
Cleanliness
Privacy, Dignity and
Wellbeing
89.44%
93.93%
96.28%
98.88%
89.13%
(BMI Three Shires PLACE collection 2015)
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The assessment is measured using a thermometer score encompassing a Pass, Qualified
Pass, Fail and Not applicable grading. We are very proud of the results for BMI Three Shires
Hospital as shown.
The audit was carried out over a 5-hour period to include all elements requested of the process
with patient assessors being recruited. The day of audit was both an integrated and enjoyable
experience and information was gleamed from our patient assessors on how we could develop
our service further.
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 Three Shires 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 100%.
Here at BMI Three Shires Hospital we aim to continue to maintain our high percentage of
compliance to patients having been VTE assessed prior to admission by continuing to audit our
practice. All staff will continue to receive training as a part of the induction process and undergo
continual development to maintain clinical competencies in line with best practice. It is our
standard practice that all patients seen at pre-operative assessment are VTE risk assessed and
a risk assessment form completed in the medical pathway.
BMI Three Shires 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 are encouraged by our data with regards to Venous Thrombo-embolism (VTE) management
and prevention. We are proud to be able to say that there have been 0 Venous
Thromboembolism (VTE) related incidents for the period of April 2014 to March 2015 at BMI
Three Shires Hospital.
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.
Here at BMI Three Shires Hospital 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
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to draw comparisons of our real time results with trusts and other providers across the
healthcare community.
April 14 – September 14
Oxford Hip Score average
Health gain between reporting
Q1
Q2
periods
BMI Three Shires Hospital
England
April 14 – September 14
*
*
18.16
40.081
21.922
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
*
*
*
19.401
36.103
16.702
BMI Three Shires Hospital
England
*
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
For the current reporting period, the tables above demonstrate the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing
hip replacement and knee replacement at BMI Three Shires Hospital on comparison with the
healthcare community in England.
BMI Three Shires Hospital have a nil (*) return for Patient reported Outcomes (PROMS) Oxford
Hip and Oxford knee as the representative sample size was not large enough for the average
health gain to be measured over time.
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
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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
Our average length of stay, combining all patient demographics, for knee replacement surgery
is 3 days and for hip replacements this is 2.85 days, 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.
Here at BMI Three Shires Hospital we are looking at further developing our ERP processes by
implementing into practice Joint Schools at the pre-assessment stage. This will enhance the
patients experience and ensures that expectations are well measured and achieved. It also
draws on expertise from a multidisciplinary team including Community Care, Carers and
Occupational Therapy to ensure that support is in place for the patient and their pathway.
Standard activities could include:
•
Discussions around Anatomy / Procedure / Postoperative goals / Expected Length of
stay in Hospital.
•
A Nurse and Physiotherapy Assessment which includes Informed Consent, measure for
anti-embolism stockings, BMI / base line observations, discharge assessment and
planning, PROMS, National Joint Registry, femoral head donation/retrieval consent.
•
Discharge Planning, expected date of discharge confirmed, commencement of setting
discharge goals and the provision of further assessment if required.
•
Full medication history to include a review of any Anticoagulant Therapy, Pain
Management, Nutritional Support – Carbohydrate Loading/preloading protocol.
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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 primary surgery undertaken.
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Unplanned Readmission within 31 days (Rate
per 100 Discharges)
0.450
0.4066
2009
0.3220
0.350
0.300
0.4022
0.3852
0.400
2010
0.2596
0.2367
0.250
2011
0.1828
0.200
2012
0.150
2013
0.100
2014
0.050
2015
2015
2014
2013
2012
2011
2010
2009
0.000
BMI Three Shires Hospital are proud of the data for ‘Unplanned Re-admissions’ and are
encouraged by the steady reduction in re-admission rate per 100 discharges for the past two
reporting periods. All unplanned readmissions <31 days are reported on in-house clinical
incident forms (CIR1 forms), entered onto our reporting software system and investigated for
appropriate practice analysis and frequency trends.
There were no trends to report for the period of appraisal and all patient care was delivered
appropriately.
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BMI Three Shires Hospital is proud of our data for ‘Unplanned Returns to Theatre’ and is
encouraged by the frequency of unplanned return per 100 discharges being lower than the
national average.
All unplanned returns to theatre are reported on in-house clinical incident forms (CIR1 forms),
entered onto our reporting software system and investigated for appropriate practice analysis
and frequency trends.
There were no trends to report for the period of appraisal and all patient care was delivered
appropriately with no adverse outcome or episode of harm being caused to our patients.
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.
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The graph above demonstrates how over 95% of our patients valued the ‘Overall Quality of
Care’ as being either very good or excellent in the 2014/15 reporting period. An achievement we
have managed to maintain from the prior period of appraisal.
Here at BMI The Three Shires Hospital we are proud of this high standard and encouraged to
note that we rate higher than the national average for patient service satisfaction. Our aim is to
continue to maintain this high standard of responsiveness to patient needs and see our patient
feedback as a fundamental opportunity to learn, commend and improve our services.
Feedback received from our patients (across all financial classes):
Very friendly,
professional and
made me feel at
ease. It was my first
hospital visit so
wasn't sure what to
expect but the staff
were great.
Very clean and tidy,
all staff are pleased
to see you and tend
to your needs with
great professional
attitude. Super
friendly people.
Thank you!
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The hospital is clean
and very efficiently
run. The staff are
marvelous, always
very friendly,
proficient and
helpful. We are
always made so very
welcome.
Everything was first
class from first
reception, through
all medical
personnel, to
caterers and
cleaners and
surroundings. Many
thanks to all!
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Three Shires Hospital actively encourages feedback both informally and formally. Information
pamphlets entitled ‘Please Tell Us..’ provide information on the available pathways and enable
us to support patients through our 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.
Written Complaints (Rate per 100 admissions)
0.900
0.8083
0.7576
0.800
0.700
0.600
2009
0.5376
2010
0.4944
0.500
2011
0.3496
0.400
0.3199
0.300
2012
2013
0.2197
0.200
2014
0.100
2015
2015
2014
2013
2012
2011
2010
2009
0.000
The Graph above identifies the frequency of our written compaints per 100 admissions.
Although there is noted to be an increase in the number of complaints recieved we are
encouraged that the number remians below the national average. BMI Three Shires Hospital
remain wholeheartedly committed to resolving all our patient concerns to mutual satisfaction
where possible and sharing the learning from such events to prevent future dissatisfaction with
our services.
4. CQUINS
The Commissioning for quality and innovation (CQUIN) framework enables commissioners to
reward a provider for its quality care and service delivery and its involvement in improved
patient outcome measures. This is done by linking a proportion of the healthcare providers'
income, from the commissioner, to the outcomes of the local quality improvement goals, which
can then be reinvested in the service.
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Both our National and Local CQUIN for the 2013/2014 period of appraisal for inclusion in these
quality accounts are as follows:
E.
Commissioning for Quality and Innovation (CQUIN)
CQUIN Table 1: CQUIN Schemes
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FRIENDS AND FAMILY TEST: EARLY IMPLEMENTATION
Indicator number
1
Indicator name
Friends and Family Test – early implementation
Indicator weighting
(% of CQUIN scheme available)
0.5%
Description of indicator
Early implementation
Numerator
Not applicable
Denominator
Not applicable
Rationale for inclusion
National CQUIN scheme
(Excerpt from 2013/2014 SAC contract)
FRIENDS AND FAMILY TEST: INCREASED RESPONSE RATE FFT
Indicator number
2
Indicator name
Friends and Family Test – Increased or Maintained
Response Rate
0.5% of contract value
Indicator weighting
(% of CQUIN scheme available)
Description of indicator
Increased or maintained response rate
Numerator
Not applicable
Denominator
Not applicable
Rationale for inclusion
National CQUIN scheme
FRIENDS AND FAMILY TEST: INCREASED RESPONSE RATE FFT IN ACUTE PROVIDERS
Indicator number
3
Indicator name
Friends and Family Test – Increased Response Rate
in acute inpatient services
0.5%
Indicator weighting
(% of CQUIN scheme available)
Description of indicator
Increased response rate
Numerator
Not applicable
Denominator
Not applicable
Rationale for inclusion
National CQUIN scheme
(Excerpt from 2013/2014 SAC contract)
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FRIENDS AND FAMILY TEST – IMPLEMENTATION OF STAFF FFT
Indicator number
Local 1
Indicator name
Friends and Family Test – Implementation of staff
FFT
0.5%
Indicator weighting
(% of CQUIN scheme available)
Description of indicator
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Implementation of staff FFT
The question must be presented in the following
order and format:
We would like you to think about your recent
experience of working at BMI Three Shires Hospital
1) How likely are you to recommend BMI Three
Shires Hospital to friends and family if they
needed care or treatment?
•
•
•
•
•
•
Extremely likely
Likely
Neither likely nor unlikely
Unlikely
Extremely unlikely
Don’t know
2) What is the main reason for the answer you
have chosen?
3) How likely are you to recommend BMI Three
Shires Hospital to friends and family as a
place to work?
•
•
•
•
•
•
Extremely likely
Likely
Neither likely nor unlikely
Unlikely
Extremely unlikely
Don’t know
4) What is the main reason for the answer you
have chosen?
Numerator
Not applicable
Denominator
Not applicable
Rationale for inclusion
Local CQUIN scheme – align with national CQUINs
for NHS acute providers to better understand staff
experience. Evidence shows that where staff report a
positive experience of working for an organisation
there is improved patient experience.
(Excerpt from 2013/2014 SAC contract)
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ENHANCED RECOVERY
Indicator number
Local 2
Indicator name
Enhanced Recovery for elective admissions
Indicator weighting
(% of CQUIN scheme available)
0.5%
Description of indicator
Numerator
A good quality pathway of care has many
components including five P's:
• Primary care ‘fitness for referral’ for common
conditions e.g. anaemia – managing the risk
• Patient involvement: shared decision making
• Prehabilitation, assessment and care planning
• Pain relief, fluid management, anaesthetics
• Preparation for and effective discharge.
Not applicable
Denominator
Not applicable
Rationale for inclusion
Quality is the driving principle of ER. ER improves
the patient experience by getting patients better
sooner, and changes clinical practice to make care
safer and more efficient. ER consists of identifying
many steps in the whole care pathway where
marginal gains can be made, leading to much better
quality outcomes.
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(Excerpt from 2013/2014 SAC contract)
We are proud to have responded appropriately to a range of national initiatives including the
Francis Report, Keogh Review and the Berwick Report and we welcome the opportunity to
continue to work collaboratively with the Commissioning Group to support continuous
improvement in our care services.
At BMI Three Shires Hospital we support eliminating patient harm as set out in the ‘Harm Free
Care’ (Institute of Innovation and Improvement, 2011 – 2013). We align ourselves with best
clinical practice and it is our continued commitment to measure patient data as set out in the
quality standard agenda to improve our care pathways.
These measures include but are not limited to audit of VTE Assessment and Prophylaxis,
Pressure Ulcers, Falls, Urinary Tract Infections (UTI) in patients with catheters, compliance with
the WHO Safer Surgical Checklist, Making Every Contact Count (MECC), lifestyle interventions
and analysis of trends in safety incidents to protect our patients from avoidable harm.
5. National Clinical Audits
BMI Three Shires Hospital was only eligible to participate in National Joint Registry audit and all
joint replacements are submitted to this. BMI hospital data is available in the latest NJS 11th
Annual Report. This details surgical data to 31 December 2013 and forms part of the
Government’s transparency agenda. It is based on procedures carried out during the 2013
calendar year and submitted to the NJR by 28 February 2014. The Results for BMI Three Shires
Hospital are as below.
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No. of
procedures
No. of
consultants
Consent
rate
Linkability
Average
ASA
Males
patients
Average
age at
operation
11
100%
96%
2.0
41%
67.8
10A rated
Acetabular
implant hip
primary
procedures
10A rated
Femoral
implant hip
primary
procedures
23%
45%
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416
Figures based on January 2013 – December 2013
National Joint registry for England and Wales
10th Annual report 2014
We do take part in NCEPOD audits when applicable to our site and we also have an active
Clinical Audit Plan. For example:
•
•
•
•
•
•
•
•
Infection Control (Care Bundles, Cleanliness and Infection surveillance)
Health & Safety
Patient Healthcare records and documentation
Oncology
Pharmacy
Theatre
Pain
Patient discharge
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
As part of our continuous quality development plans focused on improving the patient
experience, efficiency of service and highest standards of care we will be implementing four key
areas of change in 2015/16.
•
Firstly, we will commence the first stage of a three stage refurbishment project that will
transform patient accommodation to the highest quality available to both NHS and
private patients. This will include major upgrades to both patient bedrooms and
bathrooms providing a ‘fit for purpose’ environment focused solely on the care of our
patients.
•
Secondly, in order to further improve our patient pathway we will be introducing a
purpose built facility dedicated to the appropriate pre-operative assessment of patients.
This will provide an improved and seamless service, more responsive care at admission
and most importantly will make available a ‘one stop’ service to patients. This will reduce
the number of pre-operative visits required to safely risk assess the needs of patients.
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•
•
Thirdly due to an increasing demand for a dedicated Carpal Tunnel service we are
reviewing the possibility of a one stop carpal tunnel clinic though our Minor operations
facility. A consultant surgeon would, in this instance, work closely with both
Physiotherapy and Hand Therapy specialties to ensure patients receive the best
treatment from diagnosis through to rehabilitation; ensuring a positive experience and a
more efficient service in line with best practice.
Finally, to complement our extensive diagnostic capability we will be upgrading our MRI
scanner to one of the most advanced in the UK. This will provide our patients with
access to the highest quality imaging across all specialties, ensuring timely service, and
quality diagnostics.
8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI Three Shires
Hospital for the reporting period.
Unit
N/A
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
We are unable to currently compare summary hospital-level mortality indicator (SHMI) as the
HSCIC data published does not contain the independent sector.
8.2. BMI Three Shires Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
(*)
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
BMI Three Shires Hospital have a nil (*) return for Groin hernia surgery as the representative
sample size was not large enough for the average health gain to be measured. We diligently
ensure that our NHS patients complete the PROMs questionnaire tool in order to measure our
reportable outcomes and we welcome the opportunity to be able to draw comparisons of our
real time results with trusts and other providers across the healthcare community.
(ii) Varicose vein surgery
Unit
N/A
Reporting Periods
(at least last two
reporting periods)
Apr 14 – Sept 14
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National
Average
Highest National
Score
Lowest National
Score
-7.395
-1.957
-12.571
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BMI Three Shires Hospital does not currently submit Patient Reported Outcome Measures
Scores (PROMS) for Varicose Vein Surgery.
(iii) Hip replacement surgery
Unit
(*)
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
BMI Three Shires Hospital have a nil (*) return for Hip replacement surgery as the
representative sample size was not large enough for the average health gain to be measured.
We diligently ensure that our NHS patients complete the PROMs questionnaire tool in order to
measure our reportable outcomes and we welcome the opportunity to be able to draw
comparisons of our real time results with trusts and other providers across the healthcare
community.
(iv) Knee replacement surgery during the reporting period.
Unit
(*)
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
BMI Three Shires Hospital have a nil (*) return for Knee replacement surgery as the
representative sample size was not large enough for the average health gain to be measured.
We diligently ensure that our NHS patients complete the PROMs questionnaire tool in order to
measure our reportable outcomes and we welcome the opportunity to be able to draw
comparisons of our real time results with trusts and other providers across the healthcare
community.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
BMI Three Shires Hospital within 28 days of being discharged from a hospital which forms part
of the hospital during the reporting period.
Unit
N/A
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
We are unable to compare our unit of re-admissions < 28 days of discharge as our in house
system SENTINEL does not distinguish between readmissions based on age. We therefore
cannot accurately compare these figures.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the BMI Three Shires Hospital within 28 days of being discharged from a hospital which forms
part of the hospital during the reporting period.
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Unit
N/A
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
We are unable to compare our unit of re-admissions < 28 days of discharge as our in house
system SENTINEL does not distinguish between readmissions based on age. We therefore
cannot accurately compare these figures.
8.4 BMI Three Shires Hospital responsiveness to the personal needs of its patients during the
reporting period is as follows:
Unit
94.87%
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
BMI Three Shires Hospital considers that this data is as described due to our continued
commitment to our patients and the care in which they receive.
BMI Three Shires Hospital has embraced the 6C integrated strategy for improving quality of
care and patient experience at our facility. Staff have taken ownership of this framework to
embed a culture of patient centered care and are actively dedicated to improving our patient
outcomes. We aim to continue to improve on this high standard of responsiveness to patient
needs and will measure its effectiveness to improve where appropriate.
8.5 The percentage of patients who were admitted to BMI Three Shires Hospital 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 Three Shires Hospital considers that this data is as described as per the findings of our
clinical audits which demonstrate that there have been 0 Venous Thromboembolism (VTE)
related incidents for the period of April 2014 to March 2015.
Here at BMI Three Shires Hospital we audit our compliance with the requirement to VTE risk
assess every patient who is admitted to our facility which is demonstrated by our 100%
compliance.
We are proud of this achievement and aim to continue to maintain our high percentage of
patients VTE assessed by continuing to audit our practice. All staff will continue to receive
training as part of the induction process and undergo continual development to maintain clinical
competencies in line with best practice. We see this as an important initiative to further assure
our patients of our commitment to their safety and care.
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8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the BMI Three
Shires Hospital amongst patients aged 2 or over during the reporting period.
Unit
0
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
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BMI Three Shires Hospital 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.
At BMI Three Shires Hospital we have in place an SLA with a Consultant Microbiologist who has
substantive practice in the local Trust. Our dedicated team monitors and audits surveillance
data, meeting when required to assess any underlying trends in line with our patient outcomes.
The aim is to give assurance to the quality of our services. We are very proud of our dedication
to our 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 the At BMI
Three Shires 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
0
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
0
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%
Reporting Periods
(at least last two
reporting periods)
Oct 13 – Sept 14
S.GALLANT (Q&R) 18/05/2015 (V3.0) FINAL
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
BMI Three Shires Hospital 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.
Here at BMI Three Shires Hospital we are proud of our achievement for the period of appraisal
and consider this data to be very encouraging which demonstrates both our commitment to our
patients and our intentions to create a safe, effective and caring environment. 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 shared learning.
Continuing to promote a reporting and transparent culture.
8.8 The percentage of staff employed by the BMI Three Shires during the reporting period, who
would recommend BMI Three Shires as a provider of care to their family or friends.
Unit
94.43%
Reporting Periods
(at least last two
reporting periods)
Apr 2014-Mar 2015
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
BMI Three Shires Hospital considers that this data is extremely positive and demonstrates that
our staff recognise our ongoing dedication to be a passionate, responsive and effective provider
of care.
Although we are proud to have achieved this level of recommendation we want to go further in
understanding our staff’s responses and identify areas in which we can improve. In line with our
Quality Schedule for the 15/16 SAC contract BMI Three Shires Hospital are committed to
working collaboratively with the CCG to monitor our staff responsiveness and take action where
needed.
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 BMI Three Shires Hospital as a provider of care
to their family or friends.
Unit
99.27%
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 Three Shires Hospital considers that this data is positive and recognises our dedication to
provide high quality compassionate care to our patients. While the unit demonstrates that we
continue to be above the national average for England we strive towards continued
improvement on this indicator.
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We aim to do this in line with our Local 2 2015/2016 CQUIN indicator which aims to measure
our culture of responsive care against the Six C philosophy. This measures compliance against
core values of: Care, compassion, competence, communication, courage and commitment as
set out in the Chief Nursing Officer's consultation paper in 2012 and the BMI Healthcare Clinical
strategy 2013-2016.
This will enable us the opportunity to collate a more concise view of how patients view our
services against these measures and will allow us to take action and share learning accordingly.
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