BMI Woodlands Hospital
Morton Park
Darlington
Quality Accounts 2014/2015
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
BMI Woodlands Hospital Quality Accounts
April 2014 to March 2015
Hospital Information
BMI Woodlands Hospital
BMI Woodlands Hospital is set within a 5.25 acre site at Morton Park, Darlington. The hospital operates
37 beds comprising of 22 en-suite private rooms, a five bedded short stay ward, a six bedded short stay
ward and a 4 bedded high dependency level 2 unit that has been assessed and approved by the North
East Critical Care Network.
Our patient accommodation has been designed to be spacious, comfortable and bright; ensuring the
patients’ stay with us is as restful as possible. We have a rolling refurbishment programme with most of
the patient areas being redecorated throughout the last year.
Each private en-suite room is fitted with a remote controlled flat screen television, a telephone and a
nurse call system. The 5 and 6 bed wards each have a shared TV and individual nurse call system and
shared bathroom facilities. The wards areas have been assessed by the Commissioners as compliant
with the requirements to eliminate mixed sex accommodation.
Throughout the patient areas there is free Wi-Fi installed for patient and visitor use also there is free
parking available at the hospital.
The hospital has a wide bore fixed MRI scanner which can accommodate patients who have
claustrophobia and a high body mass index (BMI) we offer a mobile CT scanning service, have a fully
equipped gymnasium and an endoscopy unit in addition to the two laminar flow theatres.
We offer an extensive range of inpatient/daycase/short stay and outpatient services, supported by over
150 experienced Consultants.
We provide the very highest standards of modern medical care and we are BUPA accredited for our
breast care services.
All of the staff at BMI Woodlands Hospital are committed to ensuring the patients are confident and
comfortable with every aspect of their visit. The Director of Nursing is on hand to address any concerns
patients/visitors may have and there are Resident Medical Officers available 24 hours a day.
NHS Activity
NHS activity is undertaken at BMI Woodlands Hospital and is currently around 69% of the total volume of
work. There is an agreed ‘Standard Acute Contract’ with the local Clinical Commissioning Groups (CCGs)
and services such as Orthopaedics, Gynaecology, Urology, General Surgery, Ear Nose and Throat
(ENT), Ophthalmology and Spinal Surgery all form part of this contract. The services form part of the
Choose and Book System and BMI Woodlands Hospital is accountable for the delivery of the quality,
financial and waiting time targets that all other NHS providers have to achieve. The NHS patients are
surveyed to ascertain their satisfaction with the quality of the services and the feedback is consistently
very high.
Care Quality Commission (CQC) Registration
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the Health &
Social Care Act 2008. BMI Woodlands Hospital is registered as a location for the following regulated
services:•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Family Planning
The CQC carried out an unannounced inspection on 24 February 2014 and found that the BMI
Woodlands Hospital is fully compliant with the following standards:•
Standards of treating people with respect and involving them in their
care
•
Standards of providing care, treatment & support which meets people's
needs
•
Standards of caring for people safely & protecting them from harm
•
Standards of staffing
•
Standards of management
BMI Woodlands 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 Boards’ monitor and analyse trends and ensure that the quality
improvements are operationalised.
At a 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 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 Woodlands Hospital.
We have had: •
Zero cases of MRSA bacteraemia in the last year (NHS
1.17cases/100,000 bed days)
•
Zero cases of MSSA bacteraemia cases /100,000 bed days
•
Zero cases of E-coli bacteraemia cases /100,000 bed days
•
Zero cases of hospital apportioned Clostridium difficile in the last 12
months.
Surgical Site Infection (SSI) data is also collected and submitted to Public
Health England for orthopaedic surgical procedures. Our rates of infection
are:•
•
Zero for Hips
Two for Knees
A full hospital Infection Control and Prevention Programme is in place at BMI Woodlands Hospital which
includes monthly audits of high impact care bundles to identify compliance with infection control
processes covering:•
•
•
•
•
Surgical Site Infection
Peripheral Lines
Central Lines
Urinary Catheter Care
Aseptic non-touch technique
Audit reports demonstrate full compliance with the above care bundle pathways on a monthly basis. Hand
hygiene audits are also carried out monthly in all areas to reinforce the importance of this in maintaining
an infection free environment.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the
cleanliness of our facilities highly as the charts illustrate below:-
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 PLACE, which is the new system for assessing the quality of the patient environment, replacing
the old Patient Environment Action Team (PEAT) inspections was introduced. PLACE assessments
provide motivation for improvement by providing a clear message, directly from patients, about how the
environment or services might be enhanced.
The assessments involve patients and staff who assess the hospital and how the environment supports
patients’ 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 show how hospitals are performing nationally and locally. The results for BMI Woodlands
Hospital across the four categories assessed for 2014 are as follows:•
Cleanliness
100%
•
Food and hydration
95.26%
•
Privacy, dignity and wellbeing
93.75%
•
Condition appearance and maintenance
100%
BMI Woodlands hospital achieved an overall score of 389% out of a possible score of 400%
demonstrating the commitment of the hospital to improving all aspects of the patient experience.
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 Woodlands Hospital. BMI Healthcare was awarded the ‘Best VTE
Education Initiative Award’ category by Lifeblood in February 2013 and was 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 assess every patient who is admitted to our facility and the results of the
audit on this, has shown 100% compliance with this practice. BMI Woodlands Hospital intends to continue
this practice to ensure that patients are reassured by our safety measures.
BMI Woodlands 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 GP 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 Consultants and
referrers in order to ensure that they have as much data as possible.
The chart overleaf shows that BMI Woodlands Hospital had a rate of 0.0171 incidents of DVT per 100
admissions in 2014 demonstrating the extremely low rate of DVT incidents experienced by patients post
operatively.
1.4 Clinical Incidents – Adverse Outcome
BMI Woodlands Hospital reports all clinical incidents which occur across the departments and these are
recorded on the BMI Sentinel System. In 2014 the total number of clinical incidents reported per 100
admissions was 3.63 which is an increase on last year’s figure by 1.02. We consider that this is due to an
increased volume of activity and more complex case mix.
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 and overleaf demonstrate the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing hip
replacement and knee replacement at BMI Woodlands Hospital.
Oxford Hip Score average
April 13
Mar 14
–
BMI
Woodlands
Hospital
Q1
Q2
Health gain
periods
21.306
40.806
19.5
17.907
39.224
21.317
between
reporting
England
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'
Oxford Knee Score average
April 13
Mar 14
–
BMI
Woodlands
Hospital
Q1
Q2
Health gain
periods
19.76
36.319
16.551
18.893
34.902
16.01
between
reporting
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
The data shows that BMI Woodlands Hospital are comparative with the national average health gain for
both the Oxford Hip and Knee Score, however, the data returns are below the number required for the
results to be statistically significant, due to the lower volume of cases undertaken in comparison to NHS
Trust providers. There is currently no data available for BMI Woodlands Hospital for the period April 2014
to March 2015.
2.2 Enhanced Recovery Programme (ERP)
The ERP is about improving patient outcomes and speeding up a patients’ 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 co-morbidities,
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
The vast majority of patients that attend for surgery at BMI Woodlands Hospital follow an enhanced
recovery pathway. This involves using thorough pre-operative assessment and patient management, the
use of regional blocks for pain control and early mobilisation post -surgery.
The average length of stay (LOS) post total hip replacement is currently 2.2 days which, is well below the
NHS national average LOS and which demonstrates the effectiveness of the enhanced recovery
pathway.
Similarly, the average length of stay (LOS) for a total knee replacement at BMI Woodlands Hospital is
currently 2.4 days which is also well below the NHS national average.
The chart below illustrates the consistent improvement which BMI Woodlands Hospital has achieved in
reducing the average LOS across all surgical procedures. For 2014 the overall average LOS was 1.78
days which is a significant improvement upon the 2013 figure of 2.14
Introducing the ERP has assisted us to achieve these outcomes and work is ongoing to continually
improve on current outcomes across all specialties.
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.
The chart overleaf shows the total average unplanned readmission rates per 100 discharges for the past
5 years. As the chart demonstrates, unplanned readmissions to BMI Woodlands Hospital are very low
with the average rate for 2014 being 0.29 per 100 discharges. This is a very good performance for the
hospital against a month on month increase in activity for the same period.
BMI Woodlands Hospital has a very low rate of unplanned returns to theatre as demonstrated in the chart
below. The average for 2014 was 0.11 per 100 theatre cases.
Year to date 2015 the average unplanned return to theatre rate is 0.20 per 100 theatre cases. This may
be reflective of a more complex case mix of surgery being undertaken this year as well as a year on year
increase in volumes of activity.
The hospital Clinical Governance Committee monitors returns to theatre and each case is analysed to
ascertain whether there are improvements in practice that could be made or other preventative action
could be taken to reduce returns to theatre. None of the cases returned to theatre have required us to
make any significant changes to practice.
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 and sent to the
hospital on a monthly basis.
The patient satisfaction questionnaires ask patients specific questions around all areas of their care such
as Arrival Process, Nursing Care, Accommodation, Catering, Departure Process and Overall Quality of
Care.
Overall Satisfaction with the Arrival Process
The chart below shows overall satisfaction with the Arrival Process over this year:
The results demonstrate that 75% of patients rated BMI Woodlands Hospital’s Arrival Process as
excellent and 96% of patients rated the process as very good. In comparison to last year’s result’s there
has been a slight reduction in the excellence rating from 77% however, with regard to the very good
rating the overall annual score has remained consistent at 96%.
Improving the patient experience with the arrival process across all reception areas has been a focal point
for us this year as we recognise how important this is to patients at the beginning of their journey through
their care pathway with us.
Overall Satisfaction with Nursing Care
The chart overleaf demonstrates patient satisfaction with all aspects of nursing care over the year and
demonstrates that 83% of patients rated the nursing care as excellent at the hospital and 97% of
respondents rated it as very good. Comparing this to last year’s results the overall annual satisfaction
with nursing care has largely remained the same (84% and 97% respectively). This demonstrates BMI
Woodlands Nursing Team’s commitment to delivering a high standard of nursing care to all patients
admitted to the hospital and is a significant achievement given the increase in case mix complexity and
activity volumes from last year.
Overall Satisfaction with Accomodation
One of the areas we focus upon is patient satisfaction with the Accomodation provided to our patients at
BMI Woodlands Hospital, as we recognise this is key to maintaining privacy and dignity for patients and
improving patient wellbeing. The chart below shows the results for this year:
Over the year, 80% of our patients rated our accomodation as excellent in comparision to 78% last year
and 98% rated this as very good in comparison to 97% last year. This may be a result of a number of
improvements that we have made in the hospital which include; upgrades to decoration in the inpatient
rooms, the installation of new TVs with free view and WIFI in all of the inpatient rooms.
Overall Satisfaction with Catering
BMI Woodlands Hospital also seeks patient views on the catering provided to patients and the results are
presented for the full year in the chart overleaf which shows 76% of patients rated the catering as
excellent and 95% as very good. This is an improvement upon last years scores which were 71% and
94% respectively.
Overall Satisfaction with Discharge Procedure
Patient feedback in relation to their experience of the discharge process is important for us to understand
as it gives us a measure as to how well we have met our patients needs with regards to being discharged
home safely. The overall satisfaction for the year is demonstrated in the chart below:
Patient feedback shows an increase in the excellent rating to 76.5% from 69% the previous year with the
rating of very good remaining largely the same at 93%. The hospital teams intend to continue to work on
this area of the patient care pathway in order to ensure that patients have the best experience.
Overall Rating of Quality of Care
The chart overleaf shows how BMI Woodlands Hospital performed in terms of overall Quality of Care over
the year. This takes into account all areas of patient care and treatment as outline above.
The
percentage of respondents who rated the hospital as excellent in providing quality of care over the year is
87% and the percentage of respondents who rated the hospital as very good is 98%. The figures are
consistent with last years scores demonstrating our commitment to driving quality and safety as key
priorities across the year taking into account an increase in the total volume of activity by nearly 1500
cases.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI Woodlands
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 stage 2.
The chart illustrates the number of written complaints per 100 admissions to BMI Woodlands Hospital for
the past 6 years. As it shows, the complaint rate is very low currently standing at 0.52 per 100 admissions
year to date. The average rate per 100 admissions in 2014 was 0.35 which is lower than the current
position (YTD) but this may be associated with an increase in activity volumes across all departments and
an increase in case mix complexity on the ward and in theatres.
The main themes of complaints received by BMI Woodlands Hospital in 2014/15 includes:•
•
•
Patient dissatisfaction with elements of their care
Patient unhappiness with outcome of surgery
Dissatisfaction with administrative and billing services
Of all of the complaints received only 1 complaint was escalated to stage 2 of the complaints process in
2014 and only 1 has gone to stage 2 year to date. Most of our complaints are resolved at stage 1 at
hospital level.
The standard times for responding to complaints within BMI were achieved for most of the complaints that
the hospital received. Complaints are taken very seriously and the hospital team always reviews practice
and processes to identify any improvements that can be made where a patient has had cause to
complain in order to prevent them happening again.
4. CQUIN
The Standard Acute Contract that BMI Woodlands Hospital holds formally with local Clinical
Commissioning Groups (CCGs) includes participation in the NHS Commissioning for Quality and
Innovation Scheme (CQUIN) on an annual basis.
This involves staff working with Commissioners to deliver the national CQUIN initiatives set by the
Department of Health and to identify local CQUIN initiatives which aim to improve the quality of care
delivered to patients at hospital level. Last year BMI Woodlands Hospital was commissioned to deliver
NHS work via the Standard Acute Contract for all commissioners across County Durham and Darlington,
Tees Valley and North Yorkshire. Each required us to deliver the National NHS CQUIN initiatives which
were:1. To Improve responsiveness to personal needs of patients
1.1. Implementation of the Friends & Family Test (F&F). This required BMI Woodlands Hospital to
survey patients with the aim of asking their opinion as to whether they would recommend the
hospital to family and friends.
This was successfully implemented across the year with the introduction of a post card with 5
questions which patients were asked to complete prior to discharge from the ward. This initiative
was also rolled out across all outpatient departments and the hospital achieved feedback which
was well above the national threshold of 30%. Feedback has been very positive with 98.5% of
patients reporting that they would recommend us to family and friends as of March 2015.
2. Implementation of the National NHS Safety Thermometer
2.1. Safety Thermometer survey data for all appropriate patients.
This required BMI Woodlands Hospital to submit data on all NHS patients in hospital on a defined
day in the month reporting on instances of: pressure sores, urinary tract infections in patients with
catheters, patient falls and the incidence of VTE.
2.2. Reduction in Urinary Tract Infections (UTIs)
This indicator required that BMI Woodlands hospital report on the number of patients who had
catheters post-surgery and whether a UTI had been detected. A total of 155 patients had catheters
in post-operatively and no UTI’s were reported
2.3. Surgical Care Bundle Audits – Catheters
For this indicator BMI Woodlands Hospital were required to audit whether cases were compliant
with best practice. All catheters audited (155) were compliant against best practice for catheter
care bundles.
Local CQUIN indicators
Local CQUIN initiatives that were agreed with Commissioners included:
1. Every Health Contact Counts - This required BMI Woodlands Hospital to identify two health related
contacts with patients’ to try to improve their health and wellbeing.
•
BMI Woodlands Hospital focused upon smoking cessation as one initiative, with the aim of
identifying patients who were smoking at their pre-operative visit prior to planned surgery and
giving smoking cessation advice and literature to encourage them to stop smoking prior to
surgery and thereafter.
•
Between April 2014 and March 2015 a total of 124 patients declared they were smokers therefore
all were offered ‘Quit Smoking’ packs. Out of the 124 patients 21 patients accepted the packs to
assist them to stop smoking and 103 declined.
•
The second initiative implemented under Every Health Contact Counts, was to identify patients at
pre-assessment who were drinking more alcohol than the recommended guidelines and give
advice on staying within the national guidelines. From April 2014 to March 2015 there were no
patients identified at pre-assessment as drinking more alcohol than the national guidelines.
2. Improvements Made As a Result of Patient Experience/Feedback – This required BMI Woodlands
Hospital to improve patient experience in line with feedback from patients regarding changes required to
the environment/services/standards of care. The measurement for this was feedback through
environmental audits, the PLACE Assessment and a new group established by the hospital: Patient
Environment & Improvement Group (PEIG). As a result of patient feedback we have changed 18 of the
beds on the ward to electric beds, upgraded the TV sets, installed WIFI, implemented a rolling
programme of decoration to the inpatient rooms and made changes to some of the food offered to
patients.
3. Improve Patient Experience Focusing on Staff Attitude and Communication – this required us to
improve the overall patient experience by reducing complaints related to staff behaviours and attitude.
BMI Woodlands Hospital staff achieved this by having no reported complaints regarding staff attitude from
NHS patients.
The local CQUINs were fully delivered demonstrating our commitment to deliver the highest standards of
care possible for our patients.
CQUIN 2015/16
BMI Woodlands Hospital has agreed local CQUIN initiatives with commissioners this year to include:
1. The implementation of 48 hour phone calls to patients post discharge as a means of receiving
feedback on patient experience as a means of making improvements where required
2. To ensure that the hospital is complying with the correct use of antibiotics against a defined
antibiotic formulary
3. Looking at how we can improve the experience of patients who are carers when they require
hospital treatment
5. National Clinical Audits
BMI Woodlands Hospital was only eligible to participate in the National Joint Registry (NJR) audit. The
NJR for England, Wales and Northern Ireland collects information on joint replacement surgery and
monitors the performance of joint replacement implants. The NJR currently collects data on all hip, knee,
ankle, elbow and shoulder joint replacements across the NHS and independent healthcare sector.
Therefore all appropriate data for patients who had a joint replacement was submitted to this. Consent is
taken from patients who participate in this audit and the consent rate for 2013 – 2014 was as follows:
Quarter 1
100%
Quarter 2
64.3%
Quarter 3
77.3%
Quarter 4
67.6%
BMI Woodlands Hospital intends to try to improve its consent to audit rates for all appropriate procedures
in 2014-2015 by reviewing the data capture process.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for Service Development and Improvement
This year BMI Woodlands Hospital intends to improve and develop its services further with particular
focus on the following:
1.
2.
3.
4.
Development and expansion of Musculo Skeletal Service (MSK)
Expansion of the Endoscopy unit to attain JAG accreditation
Expansion of the overall hospital capacity
Developing Community Outreach Clinics with a number of local GP surgeries
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for BMI Woodlands
Hospital reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Oct 2012 – Jun 2014
National
Average
Highest National
Score
Lowest National
Score
0.9987
1.1849
0.58345
BMI Woodlands Hospital has not had any perioperative or postoperative deaths in the reporting period
and therefore, is below the national average for the SHMI. The hospital intends to continue to implement
best practice in relation to patient safety and quality initiatives and clinical effectiveness to maintain this
position.
8.2 BMI Woodlands Hospital Patient Reported Outcome Measures (PROMS) scores for ;
(i) Groin hernia surgery
Unit
0.019
Reporting Periods
(at least last
reporting periods)
Apr 14 – Sept 14
National
two Average
0.0786
Highest
Score
0.278
National Lowest
Score
National
-0.112
BMI Woodlands Hospital is slightly below the national average for health gain following groin hernia
surgery but is significantly ahead of the lowest national reported score. It should be noted however, that
due to the very low numbers carried out at the hospital the data is unlikely to be statistically significant.
(ii) Varicose vein surgery
Unit
NA
Reporting Periods
(at least last
reporting periods)
Apr 14 – Mar 14
National
two Average
-7.395
Highest
Score
-1.957
National Lowest
Score
National
-12.571
BMI Woodlands Hospital has moved away from surgical intervention for varicose veins and most are
treated via an ablation technique performed under ultrasound control (VNUS). This is not monitored under
the auspice of PROMs.
(iii) Hip replacement surgery
Unit
*
Reporting Periods
(at least last
reporting periods)
Apr 14 – Sept 14
National
two Average
21.542
Highest
Score
28.6
National Lowest
Score
National
9.714
Last year BMI Woodlands Hospital was above the national average for health gain post hip replacement
surgery. This is possibly due to the Enhanced Recovery Pathway that is followed by most of the
surgeons operating from the hospital and the multi-disciplinary team working approach towards achieving
best practice. *Data for the above reporting period is not available at this time.
(iv) Knee replacement surgery
Unit
*
Reporting Periods
(at least last
reporting periods)
Apr 14 – Sept 14
National
two Average
16.641
Highest
Score
24.429
National Lowest
Score
National
5.833
BMI Woodlands Hospital is significantly above the national average for health gain post knee replacement
surgery. As with the comments above regarding hip replacement this is possibly due to the Enhanced
Recovery Pathway which we implement at the hospital. *Data for the above reporting period is not
available at this time.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the BMI
Woodlands Hospital within 28 days of being discharged during the reporting period.
Unit
NA
Reporting Periods
(at least last
reporting periods)
Apr 13 - Mar 14
National
two Average
11.45
Highest
Score
14.35
National Lowest
Score
National
7.96
BMI Woodlands Hospital does not admit patients aged 0-14 years of age and therefore this is not
applicable.
8.3. (ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of the BMI
Woodlands Hospital within 28 days of being discharged from a hospital during the reporting period.
Unit
0.29%
Reporting Periods
(at least last
reporting periods)
Apr 13 – Mar 14
National
two Average
10.01
Highest
Score
14.51
National Lowest
Score
National
5.54
The number of readmissions to BMI Woodlands Hospital during 2014 was extremely low with the actual
percentage being 0.29%. This equates to 18 patients in 6091 admissions to the hospital during this time
period. This is significantly below the national average and the lowest national score as outlined in the
table above.
Readmissions often occur due to complications of surgery. Staff at BMI Woodlands Hospital encourage
patient’s to come back to the hospital so that we can treat them as efficiently and effectively as possible if
they encounter a problem following surgery. Each time a patient is readmitted to the hospital as an
inpatient the case is discussed at the Clinical Governance Committee meeting and if any changes to
practice are required then these are actioned and implemented accordingly.
8.4 BMI Woodlands responsiveness to the personal needs of its patients during the reporting period.
Unit
97.91
Reporting Periods
(at least last
reporting periods)
2013-2014
National
two Average
68.7
Highest
Score
85
National Lowest
Score
National
54.4
BMI Woodlands Hospital’s responsiveness to the personal needs of its patients scores very highly and far
surpasses the national average and the highest national score. We consider this to be the case due to the
drive to consistently improve the patient experience within the hospital teams.
This year the hospital implemented a ‘Patient Environment and Improvement Group’ (PEIG) on which,
patient representatives and members from the local Health Watch Board sit. This group meets quarterly
and seeks to make improvements in line with patient feedback and observations.
8.5 The percentage of patients who were admitted to BMI Woodlands Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
100%
Reporting Periods
(at least last
reporting periods)
Apr 14 – Jan 15
National
two Average
95
Highest
Score
100
National Lowest
Score
National
87
BMI Woodlands Hospital has an excellent track record for this indicator, surpassing the national average
and equaling the highest national score. The hospital staff will continue to implement best practice in VTE
management in order to maintain this position.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within BMI Woodlands
Hospital amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last
reporting periods)
Apr 13 – Mar 14
National
two Average
14.7
Highest
Score
37.1
National Lowest
Score
National
0
BMI Woodlands Hospital has not had any episodes of Clostridium Difficile reported for the period April
2013 – March 2014 and considers that this is because of the strong focus upon infection prevention and
control (IPC) within the hospital. Staff aim to continue with the IPC programme and implementation of
best practice to maintain this excellent standard.
8.7 The number and, where available, rate of patient safety incidents reported within BMI Woodlands
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
229
Reporting Periods
(at least last
reporting periods)
Oct 13 – Sep 14
National
two Average
20
Highest
Score
National Lowest
Score
139
National
0
Rate of patient safety incidents reported (Incidents per 100 Admissions)
Unit
3.75
Reporting Periods
(at least last
reporting periods)
Oct 13 – Sep 14
National
two Average
3.589
Highest
Score
National Lowest
Score
7.496
National
0.0245
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last
reporting periods)
Oct 13 – Sep 14
National
two Average
40.2
Highest
Score
97
National Lowest
Score
National
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100
Admissions)
Unit
0
Reporting Periods
(at least last
reporting periods)
Oct 13 – Sep 14
National
two Average
0.3
Highest
Score
2.4
National Lowest
Score
0.0
National
BMI Woodlands Hospital reports all clinical incidents and patient safety related incidents. The number
reported above includes a high proportion of patients who were planned as day cases and for clinical
reasons stayed overnight, which is classed as an adverse outcome on the BMI Sentinel reporting system.
As well as using different reporting methodology, BMI Healthcare use a different reporting system to the
NHS and therefore, some of our results cannot be directly comparable with the NHS data. This can be
demonstrated when looking at the number of patient safety incidents reported which stands at 229 for
BMI Woodlands Hospital and the figure appears to be higher than the national average score which is not
reflective of the true position.
There has been one incident which was classed as a serious untoward incident but this did not result in
any actual harm to the patient.
The hospital has put systems and processes in to place to prevent the incident from occurring again and
we work very hard to ensure that patient safety is our highest priority as a hospital.
8.8 The percentage of staff employed by the BMI Woodlands Hospital during the reporting period, who
would recommend the hospital as a provider of care to their family or friends.
Unit
99
Reporting Periods
(at least last
reporting periods)
2014
National
two Average
64.58
Highest
Score
96.43
National Lowest
Score
National
33.73
BMI Woodlands Hospital scores well above the national average for this indicator and above the highest
national score recorded, demonstrating the faith that employees have in the care that is delivered within
the hospital. Many staff and family members have been treated successfully at BMI Woodlands Hospital
in recent years.
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 Woodlands Hospital as a provider of care to their family
or friends.
Unit
88.58
Reporting Periods
(at least last
reporting periods)
Jun 13 – Jan 14
National
two Average
66.23
Highest
Score
94.38
National Lowest
Score
National
35.63
The percentage of patients who would recommend BMI Woodlands Hospital to family and friends is
currently 88.58% which is significantly higher than the national average. It should be noted however, that
there was an average 26% return rate for patient satisfaction feedback surveys during the reporting
period and significant work has been done this financial year to increase the number of patients reporting
against this indicator.
This concludes the quality accounts for BMI Woodlands Hospital for 2014/ 2015 if you would like to
discuss any aspect of this report please do not hesitate to contact Debbie Dobbs (Executive Director) or
Jill Neasham (Director of Nursing).