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 Winterbourne Hospital (WBH) was purpose built in the 1980’s, in Dorchester, Dorset and
has 38 beds all of which are en-suite. Patient room facilities include satellite TV, telephone and
WiFi. The hospital has two operating theatres, a physiotherapy department with a hydrotherapy
pool, diagnostic imaging department with screening, ultra sound and mobile imaging (c arm)
and a 2 bedded High Dependency Unit (HDU). The hospital was opened 30 years ago.
The patient floor area is on one floor and is laid out in a ‘race track’ design which allows for
efficient staffing of patient peaks and troughs.
The hospital also benefits from a purpose built conference room which is regularly used for
external events (GP and public) and staff and CCG meetings. It is a valuable marketing and
training resource.
The Winterbourne has 84 Consultants that offer a wide range of surgical specialties included
complex surgeries such as spinal, vascular and colorectal. Some services are offered to the
NHS via Choose & Book, these include orthopaedic hip & knee, foot & ankle, and shoulder.
Also, general surgery hernia clinics along with thyroid surgery and ophthalmic clinics offering
local anesthetic cataract services. Currently, 40% of activity is NHS in origin.
The rating for The Winterbourne, in terms of patients’ satisfaction, has increased by moving
from bottom of the league table in 2012 to number 15 nationally in February 2014, and as high
as number 11 over previous months. This has been achieved by changing the culture across
the hospital and by putting the patient at the heart of everything we do.
Significant investment has been made in kit & equipment to allow specialties to grow e.g. hip
arthroscopy kit used for both private and NHS patients. Investment has been targeted to focus
specialties that include; a new ultrasound machine, a new Pentax camera system for outpatient
urology, Visual fields machine for ophthalmology.
Progress has been made in developing complex urology treatments; prostate mapping, Hifu,
laser stone treatment and most recently Holmium Laser prostatectomy (Holep) is now offered.
This service will be greatly enhanced when the static MRI is installed with the facility to MR scan
prostate glands.
General upgrading of standard equipment such as electric beds, patient monitoring and patient
room furniture have also be completed on a rolling program of improvement to the look and feel
of the accommodation.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The Winterbourne Hospital is registered as a location for
the following regulated services:•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Family Planning Service
The CQC carried out an unannounced inspection on 8th January 2014 and found
Care and welfare of people who use services
Meeting nutritional needs
Supporting workers
Complaints
BMI The Winterbourne 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.
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 BMI The Winterbourne
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
Winterbourne Hospital.
We have had: • MRSA bacteraemia cases 0/100,000 bed days
• MSSA bacteraemia cases 0 /100,000 bed days
• E.coli bacteraemia cases 0/100,000 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. Our rates of infection are;
o Hips = 1
o Knees = 2
At BMI The Winterbourne Hospital we aim to foster a culture of zero tolerance for infection
following hip and knee surgery. We will continue to employ robust reporting systems to ensure
our very low rates for infection continue.
Regular monthly IPC audits are carried out to ensure compliance with national and local IPC
standards. Hand hygiene remains high on the clinical agenda as a means of continuously
improving IPC standards and safeguarding our patients and visitors. Significant improvement in
hand gel use was demonstrated in the most recent audit, particularly during the transfer of
patients (in beds) from one department to another.
High Impact Intervention Care Bundles are also regularly audited and include, Peripheral
Cannula care, Urinary Catheter Care and Surgical Site Infections (SSI). The audit results for
SSI show 100% compliance with relevant NHS and BMI policies within both the theatre
environment and post-surgical care on the ward with, for example, no surgical wound dressings
being removed within the standard 48 hours post-operatively. The results for both Peripheral
Cannula Care and Urinary Catheter care also show a very high level of compliance at 100%.
Hand hygiene surveillance is carried out on a monthly basis in different clinical areas of the
hospital. The areas in which nursing staff practice have been clearly demonstrated to be
delivering a high level of compliance and there is a focus on this audit within other clinical areas
in order to demonstrate our commitment to IPC standards. Aseptic Non-Touch Technique has
become an increasingly important aspect of surgical wound care and as a direct result and in
order to ensure compliance with up-to-date, evidence based practice, nursing staff are enrolled
on the Corporate education and training programme. Compulsory Mandatory training sessions
continue to provide the rationale for rigorous attention to hand washing and the significant
improvements are demonstrated in the audited results. The engagement of a new, highly
experienced and qualified IPC Lead Specialist Nurse, has helped us to continue the focus on
areas that remain high on the quality agenda. This is particularly evident in the peri-operative
phase of patient care, when body core temperature is of paramount importance to positive
outcome. Core body temperature recording has been significantly improved with the
introduction of infra-red non-touch thermometers in all clinical areas of the hospital.
There has been a recent emphasis on education and training in aseptic non-touch technique
(ANTT) in order to improve knowledge and skill and see this transferred in to direct patient care.
There is continued commitment to infection prevention systems and processes at BMI The
Winterbourne Hospital and, in particular, the needs of our patients. IPC audits are conducted
rigorously to ensure compliance and include the following:
•
World Health Organisation (WHO) Hand Hygiene
•
•
•
•
Theatre Asepsis - Standard Precautions
Central Venous Catheter Audit Bundle
Urinary Catheter Audit Bundle
Peripheral IV Cannula Care audit Bundle
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 95% of our
service users consistently found our facilities either ‘very good’ or 'excellent.’
The graph below demonstrates our commitment to constantly improving the service we deliver
to our patients, and demonstrates a year on year improvement in this key quality area. BMI The
Winterbourne Hospital is particularly proud of these achievements as it is our patients and
service users who provide the feedback so essential to enable us to maintain and monitor these
high standards.
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 for the hospital in
2014 demonstrate an overall cleanliness rating of 99.72% which compares extremely well against a
national average score of 97.25% and very well within the BMI Healthcare group of hospitals. We
are confident that the continued focus on high standards of cleanliness of the individual patient
environment has resulted in tangible improvement and benefit for patients. The patients we care for,
and their relatives and carers can, therefore, be confident that cleanliness within the hospital
environment will remain a continuing important area of focus.
In 2012 the National Institute for Clinical Excellence (NICE) produced new guidance in relation
to two very important aspects of care; Respect and Dignity. BMI The Winterbourne Hospital is
extremely proud of the positive feedback we have received from patients on this issue. Our
nursing teams have firmly embedded this key quality indicator in to their everyday practice.
Patient feedback remains very positive and we continue to strive to ensure that all patients are
cared for with respect and have introduced measures to ensure that dignity is rarely
compromised. A ‘dignity tree’ has been placed on the ward and in the main reception area
where patients and visitors alike are invited to write down their thoughts on a paper leaf and
then attach it to the tree. We have received many compliments, not only for the concept but
also for the care and attention to detail they receive whilst in our care.
1.3 Venous Thrombo-embolism (VTE)
BMI Healthcare, holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including, BMI The Winterbourne 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% of inpatient and day-case patients
have an appropriate VTE risk assessment carried out at Pre-operative assessment and/or on
admission and within 24 hours of admission.
BMI The Winterbourne 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.
VTE (Rate per 100 admissions)
0.050
0.0456
0.045
0.040
0.035
2009
0.030
2010
0.0237
0.025
2011
0.0212
2013
0.010
2014
0.005
0.0000
0.0000
0.0000
2014
2012
0.015
2013
0.020
2012
2011
2010
2009
0.000
During the last year there have been three incidences of post-operative VTE at BMI The
Winterbourne Hospital. However as our data demonstrates the incidence per 100 patients. Our
priorities are to continue the close liaison with the wider health community and ensure that VTE
advice is reinforced with patients, to further reduce the incidence of VTE at BMI The
Winterbourne 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.
For the current reporting period, the tables below demonstrate that the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing
hip replacement and knee replacement at BMI The Winterbourne Hospital during the stated
period. The outcomes demonstrate a higher than national health gain for patients and a greater
satisfaction rate with their surgery.
Oxford Hip Score average
April 14 – December 14
BMI The Winterbourne
Hospital
England
Q1
Q2
Health gain between reporting
periods
21.111
43.444
22.333
18.16
40.081
21.922
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
April 14 – September 14
Oxford Knee Score average
Health gain between reporting
Q1
Q2
periods
BMI The Winterbourne
21.143
34.500
13.357
England
19.401
36.103
16.702
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
knee replacement at BMI The Winterbourne Hospital on comparison with the healthcare
community in England. The overall perceived, and reported, health gain by patients is below
that of the wider health community in England and may be indicative of a need to provide these
patients with a greater level of pre-and post-operative information in relation to the recovery
period.
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 to 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
At BMI The Winterbourne Hospital we have established a pre-operative information giving
process for patients undergoing hip or knee replacement surgery and for certain specialized
shoulder surgery that includes a one-to-one discussion about length of stay, the operative
procedure, expected goals and discharge planning. This is a multi-disciplinary service, led by
our physiotherapy team, who together with the pre-operative assessment nursing staff, ensure
that care is individualized to patient needs.
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 re-admissions to hospital and unplanned returns to theatre are usually as a result of
clinical complications of surgery. The rates for both at BMI The Winterbourne Hospital have
significantly improved over the last 5 years, as demonstrated in the above illustrations. We
strive to ensure that all surgical patients are discharged from hospital with the appropriate level
of information and have direct access to clinical assistance from our dedicated teams within the
first 30 days from discharge.
Unplanned returns to theatre are generally as the result of complications of surgery, and
continue to be a rare event. At BMI The Winterbourne Hospital we ensure that all surgical
patients are fully informed and, therefore, have sufficient, appropriate information, both verbal
and written to be able to make an informed decision and understand the risks and benefits of
their surgery. The chart below demonstrates patient satisfaction with this aspect of their care.
There will remain a need to ensure that the amount and quality of information provided to
patients at the initial consultation, during pre-operative assessment and on admission is
meaningful and relevant to each individual patient. We are confident that the focus on patientcentered information giving will continue.
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. The chart below demonstrates our continued commitment to ensuring that we exceed the
expectations of our customers and service users. Whenever the results show a shortfall we
investigate quickly and produce an action plan for improvement.
Category
Admission process
Nursing care
Accommodation
Catering
Discharge process
Overall Quality of Care
March
2013
63.4
71.7
64.6
64.3
61.0
75.7
% Excellent
March
March
2014
2015
69.9
66.1
80.8
77.5
64.4
72.1
71.1
77.0
66.3
62.9
76.4
79.5
March
2013
90.3
92.1
92.4
89.9
89.0
95.9
% Satisfied
March
2014
94.9
96.5
93.3
90.0
88.7
98.2
March
2015
95.5
95.1
94.8
95.1
97.2
98.2
From April 2013 the NHS introduced the Friends & Family test across all NHS Trusts and
Independent Providers of NHS care. We believe that the important question: Would you
recommend this service to your friends or family” should be rolled out to all our customers,
whether NHS or Private Patients and across all of our services as a means of gaining feedback
from which to establish clear actions for improvement. Fluctuations in scoring provide us with
specific areas on which to focus our attention for continuous improvement.
BMI The Winterbourne Hospital is extremely proud that since launching this mandated
programme we have had consistently positive feedback from our customers with a 100%
recommendation rate over the 12 months to March 2015.
Our ranking for patient satisfaction within the BMI Healthcare group is of great importance to our
customers and to the staff who provide our services. We have continued to focus on the patient
experience and as a result BMI The Winterbourne Hospital ranking within the Group has
improved from 45th out of 55 hospitals to 5th out of 55 hospital in the 12 months from March
2014 – 2015.
What patients comment about the service provided at BMI The Winterbourne
“Just excellent, friendly
service.”
“Service totally
brilliant.”
“Very professional, efficient care in pleasant environment with skilled staff.”
“The staff are very pleasant to talk to and were very forthcoming with the information that was asked “
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Winterbourne 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.
Where appropriate, the Executive Director and Director of Nursing meet with patients to ensure
that a complete picture of the patient experience is achieved. This process allows for individual
and group reflection on incidents and complaints and contributes to the improvement goals for
the hospital. From 2013 through 2014 and in to 2015 there has been a downward trend in the
number of patient complaints, particularly those relating to direct patient care. We firmly believe
that the initiatives and improvements made so far have had a significant positive impact on
patient care. Improvement plans will continue to develop the service and, we believe, reduce
the number of adverse incidents and patient complaints.
Audit results show that 100% of complaints received an initial response within 48 hours of
receipt and 100% receiving a full response within the required 20 days.
Written Complaints (Rate per 100 admissions)
0.800
0.6885
0.700
0.6496
0.600
0.5386
0.5013
0.500
0.4283
2009
2010
0.400
2011
0.2974
2012
0.300
2013
0.200
2014
0.100
2014
2013
2012
2011
2010
2009
0.000
At BMI The Winterbourne Hospital we aim to continuously improve our services by listening to
the feedback we receive from patients and taking appropriate action, where necessary, to make
the improvements to prevent a recurrence. There have been 17 complaints since January
2015. Two of which are related to the care received. The remainder relate to matters of
finance. The general trend on complaints demonstrates that there is an overall improvement in
direct patient care.
4. CQUINS
Commissioning for Quality and Innovation is an NHS led programme offering additional
funding to improve quality and encourage innovation. The NHS mandates national CQUINS
and negotiates at local level for further CQUINS. For the 2014/15 year the National
measures were:
•
VTE Risk Assessment
•
Patient Experience
•
Safety Thermometer
•
Dementia Screening and onward referral
•
Smoking Cessation and onward referral
Goal
number
1
Goal Name
Description
Update
Friends and
Family Test Early
Implementation
Friends and
Family Test Increased or
Maintained
Response Rate
Early Implementation
Increased or maintained response rate
F&F test question: 100% would
recommend our services to
friends and family.
2
NHS Safety
Thermometer
3.
Dementia
4
VTE
To reduce harm. The power of the
NHS Safety Thermometer lies in
allowing frontline teams to
measure how safe their services
are and to deliver improvement
To identify those patients with
symptoms of dementia and other
causes of cognitive impairment
alongside their other medical
conditions, to prompt appropriate
referral and follow up after they
leave hospital and to ensure that
hospitals deliver high quality care to
people with dementia and
support their carers.
To reduce avoidable death,
disability and chronic ill health from
venous thromboembolism (VTE)
5
Care Bundle
Audits,
Catheters
To demonstrate quality perioperative
care
6
Post-surgical
Remote FollowUp
Digital First
To reduce
unnecessary face to face
appointments
Accepted numbers of F&F cards
submitted is down month on
month due to lack of
information being incorporated
on form. Process for
improvement implemented
immediately.
Monthly data submission to
IMU.
Screening question asked of all
relevant patients on Preadmission appointment or
admission to hospital. Nil
return to date
All clinically eligible patients
have assessment for VTE and
prophylaxis at Pre-admission
appointment admission.
Quarterly BMI detailed audit
also performed in addition to
monthly return to IMU
Care bundle is commenced for
patients with indwelling urinary
catheter. Any adverse incidents
to use of urinary catheter is
captured and submitted via the
Patient Safety thermometer
data and within IPC standard
data capture.
All day-case patients, both NHS
and private are routinely
contacted at 48 hours postsurgery. Follow up
appointments are on standard
Consultant discharge
instruction only. All cataract
patients are reviewed in line
Goal
number
Goal Name
Description
Update
with best practice pathway at 2
weeks post procedure.
7
Health
Promotion
To support healthy lifestyles and
making every contact count
8
Care Bundle
Audit - Peripheral
Vascular Access
Device
Reduce complications associated with
the use of peripheral vascular access
device.
9
Mobilisation of
patients
following Hip or
Knee surgery
Patients who have had Hip or Knee
surgery, to be mobilised within 24
hours of surgery.
BMI of all patients is calculated
at pre-admission. Access to
weight loss management
services is offered where the
BMI exceeds 30.
Quarterly audit programme in
place. Data submitted to
Regional Quality & Risk team.
All appropriate patients who
meet the criteria are added to
the Enhanced Recovery
Programme. Current position
with TKR and THR are within
National recommendations.
5. National Clinical Audits
BMI The Winterbourne 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 NJS report. Use this if appropriate with your narrative on the data and any
improvement plans.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
BMI The Winterbourne Hospital continue with planning to improve and upgrade services to our
customers. We are currently in the latter stages of procuring a static MRI scanner which will
enable us to offer greater appointment choice and increased capacity for this diagnostic test.
We have had a mobile scanner on site every week for one day which has recently needed to
increase to two days.
The ever-changing and improving surgical techniques have reduced the length of stay for many
patients and with this in mind, BMI The Winterbourne Hospital have put forward a proposal to
establish an ambulatory care area for patients who do not need to have an overnight stay in
hospital. This new initiative will greatly improve the flow of patients through their surgical
pathway and will be facilitated by our proposed third theatre. The space for the third theatre is
already in place and we await final approval and funding to have this area commissioned for
use.
In addition to these developments we continue with our rolling programme of refurbishment of
individual patient rooms.
8. Mandatory Quality Indicators
8.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI The
Winterbourne 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
8.2 BMI The Winterbourne Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.759
Reporting Periods
(at least last two
reporting periods)
Apr 14 – May 15
National
Average
Highest National
Score
Lowest National
Score
0.0786
0.278
-0.112
BMI The Winterbourne Hospital considers that this data compares extremely favourably against
the national average which may indicate the greater satisfaction of our patients undergoing this
surgery.
(ii) Varicose vein surgery
Unit
N/A
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
National
Average
Highest National
Score
Lowest National
Score
21.542
28.6
9.714
(iii) Hip replacement surgery
Unit
24.889
Reporting Periods
(at least last two
reporting periods)
May14 – May 15
BMI The Winterbourne Hospital considers that this data compares favourably against the
national average and may indicate the success of the integrated care pathway that ensures a
truly multi-disciplinary approach to care that involves the patient in their own care.
BMI The Winterbourne Hospital will work closely with all members of the multi-disciplinary team
involved in the care of this group of patients to improve perceived out comes for patients
undergoing Knee replacement surgery.
Unit
13.923
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 The Winterbourne Hospital considers that this falls below that of the national average and
may be a multi-faceted reflection of the care pathway and the perceived expectations that Knee
replacement patients present with.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
(Winterbourne 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
BMI The Winterbourne Hospital is unable to compare our unit to re-admissions < 28 days from
discharge because the corporate risk reporting system, Sentinel, is not able to distinguish
between re-admissions based on age.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
BMI The Winterbourne Hospital, within 28 days of being discharged from a hospital which forms
part of the hospital during the reporting period.
Unit
*
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 Winterbourne Hospital considers that this data is as described due to the fact that the
corporate risk reporting system is currently unable to identify and/or distinguish re-admission
type based on age.
8.4 BMI The Winterbourne Hospital’s responsiveness to the personal needs of its patients
during the reporting period.
Unit
%
Reporting Periods
(at least last two
reporting periods)
2013-2014
National
Average
Highest National
Score
Lowest National
Score
68.7
85
54.4
BMI The Winterbourne Hospital considers that this data is as described for the following
reasons due to concerted and focused efforts to constantly improve our service based on the
feedback received from service users.
BMI The Winterbourne Hospital has embraced the National 6C’s strategy for improving quality
of care and patient experience at our facility. Our 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. Our Health Care
Assistants are working, under the supervision of the Registered Nursing Staff, to ensure that
this strategy remains a focus for service improvements.
8.5 The percentage of patients who were admitted to BMI The Winterbourne 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
The Winterbourne Hospital considers that this data is as described following rigorous audit.
Strict compliance to the VTE policy has ensured that 100% of patients, for whom VTE
assessment is relevant, are assessed at pre-admission, this is re-assessed on the day of
admission and, for inpatients, again 24 hours following admission. We are proud of the very low
incidence of VTE at this hospital. There have been 2 cases within the previous 12 months.
We continue to work as closely as possible with our Consultant colleagues and with our NHS
colleagues to determine clear reporting of VTE.
All clinical staff undergo training to ensure their knowledge and competence in this field is up-todate and forms an important aspect of their continuous professional development in accordance
with national guidance. This important initiative is perceived by our staff as a demonstration of
the ongoing commitment to patient safety and well-being.
The rate per 100,000 bed days of cases of C difficile infection reported within BMI The
Winterbourne 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
BMI The Winterbourne Hospital considers that this data is as described due to our commitment
to ensuring a safe environment in which to deliver a high standard of care.
At BMI The Winterbourne Hospital we have in place an SLA with a Consultant Microbiologist
who provides support and guidance to staff on clinical issues that are relevant to infection. Our
dedicated clinical 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 commitment to our Infection Prevention
and Control (IPC) strategy and aim to maintain the high standards already achieved, and where,
necessary, improve on them.
8.7 The number and, where available, rate of patient safety incidents reported within BMI The
Winterbourne 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
National
Average
Highest National
Score
Lowest National
Score
0.3
2.4
0.0
BMI The Winterbourne Hospital considers that this data is as described due to our dedication
and ongoing commitment to ensuring a safe environment in which to deliver a high standard of
care.
BMI The Winterbourne Hospital is proud of our achievement for the period of appraisal and
considers 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
• Commitment to a culture of ‘no blame’, where learning is shared to prevent or reduce the
risk of recurrence
• Commitment to a culture of transparency in relation to incident reporting
8.8 The percentage of staff employed by BMI The Winterbourne hospital during the reporting
period, who would recommend this Hospital as a provider of care to their family or friends.
Unit
98%
Reporting Periods
(at least last two
reporting periods)
2014
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
BMI The Winterbourne Hospital considers that this data is as described due to the dedication
and commitment of staff to the delivery of high quality care that is responsive, effective,
compassionate and individualized care.
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 The Winterbourne Hospital as a provider
of care to their family or friends.
Unit
98.4%
Reporting Periods
(at least last two
reporting periods)
Jun 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
BMI The Winterbourne Hospital considers that this data is very positive, particularly as there
continues to be an emphasis on continuous improvements to the service we deliver to our
patients. The commitment of all staff, both clinical and non-clinical to the delivery of high quality
care has demonstrated an improvement which we aim to sustain and not allow ourselves to lose
focus.