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.