BMI Chelsfield Park Hospital Quality Accounts
April 2013 to March 2014
Chief Executive’s Statement
Welcome to our Quality Accounts 2014, the fifth year we have published
this data. The information presented here on a broad range of quality
measures continues to grow in importance and usefulness for patients and
commissioners. Quality accounts already provide a key metric for people to
assess the strength of our 66 hospitals and clinics against other facilities NHS and independent - from which they might receive their care.
For BMI Healthcare and every other private provider the importance of
comparable quality data was recently reinforced by the conclusions of the
Competition Commission’s market investigation into private healthcare.
From the outset of the inquiry BMI Healthcare supported the principle that
competition in the sector would be enhanced if private hospitals produced
comparable quality data, and that competition amongst hospitals would
drive up service standards. We were therefore fully supportive when the
Commission announced in April that it is mandating the provision of greater
information on the performance of hospital operators and consultants. We
wholeheartedly agree when the Commission says that “a more transparent
market with patients actively making choices will drive hospital operators to compete on the things
that matter to patients”.
Whilst we are yet to see how the Commission will ensure that this is enacted, the private sector
continues to take its own steps. Five years ago BMI Healthcare was at the forefront of the sector’s
efforts to be more open about sharing comparable quality and pricing data when we sponsored the
launch of the Hellenic Project. Today that work has been superseded by the Private Hospitals
Information Network which is working towards publishing data that will allow patients and
commissioners to make informed choices - a challenge that the sector must now rise to. We at BMI
Healthcare will continue to play our part in these important developments, which we believe can
have a significant role in driving higher quality standards.
I remain proud, but certainly not complacent, about the quality of care our hospitals provide. Last
year BMI Healthcare invested £40m in our hospitals, supporting our committed staff and consultants
to meet the challenge of providing consistently safe, high quality care. We constantly measure our
patients’ experience, and I am pleased to note that in the three months to the end of March 2014,
97.3% of patients independently surveyed expressed satisfaction with their care and 97.9% said
they would recommend us to others. There is however always room for improvement, and
publication of comparable quality data across the independent sector can only help.
The information available in these quality accounts 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.
I thank all the staff whose energy and devotion to improvement is represented here and, more
importantly, in the experiences of every patient who steps across our threshold.
Stephen Collier
Chief Executive Officer
BMI Chelsfield Park Hospital
BMI Chelsfield Park Hospital, situated in Chelsfield Village on the outskirts of Orpington is part of the
BMI Healthcare group of hospitals. The hospital has 37 beds and provides a range of elective
services across most general specialties, with the exclusion of Psychiatry and Maternity services.
The hospital has two wards, including a 2 bed High Dependency Unit, 2 Main Operating Theatres
and Recovery Unit, a Minor Procedures Theatre, 7 Consulting Rooms, Assisted Conception Unit,
Imaging Department, mobile MRI, Oncology Suite, Pharmacy Department and a Physiotherapy
Department. The hospital does not have an Intensive Therapy Unit, therefore, specialties are limited
and patients are screened to ensure that a need for ITU is not anticipated. Catering and
Housekeeping services are managed as in-house services.
The hospital provides specialist services in Bariatric Surgery and received accreditation from the
International Federation for the Surgery of Obesity and Metabolic Disorders [IFSO] as a Bariatric
Surgery Centre of Excellence. This service is supported by a specialist multi-disciplinary team.
The hospital has an HFEA accredited Assisted Conception Unit which is clinician led and supported
by specialist nurses and embryologists.
The hospital also admits children from the age of 3 years old for minor elective surgical procedures
as day case or one overnight stay. Paediatric nursing care is provided by Registered Children’s
Nurses.
Other Specialist Nurses support High Dependency, Oncology and Breast Care services within the
hospital.
During financial year 2013/2014 approximately 16% of the hospital’s patients were NHS funded
under the Standard Acute Contract, directly commissioned services or through funding from the local
NHS Trust.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Chelsfield Park 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 18th December 2013 and found the hospital to
be compliant with the following standards.
Consent to care and treatment
Care and welfare of people who use services
Meeting nutritional needs
Cleanliness and infection control
Complaints
BMI Chelsfield Park 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 Groups monitor and analyse trends and ensure that the quality
improvements are operationalised.
At corporate level the Clinical Governance Board has an overview and provides the strategic
leadership for corporate learning and quality improvement.
There has been ongoing focus on robust reporting of all incidents, near misses and outcomes. Data
quality has been improved by ongoing training and database improvements. New reporting modules
have increased the speed at which reports are available and the range of fields for analysis. This
ensures the availability of information for effective clinical governance with implementation of
appropriate actions to prevent recurrences in order to improve quality and safety for patients, visitors
and staff.
At present we provide full standardized 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 Infection Prevention & Control Lead in BMI
Chelsfield Park 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 in the last year.
• Zero cases of E.coli bacteraemia in the last year.
• Zero cases of hospital apportioned Clostridium difficile in the last year.
• SSI data is also collected and submitted to Public Health England for orthopaedic surgical
procedures.
An Infection Prevention & Control Audit Programme is in place to ensure that all hospital areas are
inspected and assessed against Infection Prevention & Control best practice standards.
In 2012 Care Bundle Audits were implemented to assess and improve practice in relation to :• Insertion and Ongoing Care of Central Venous Catheters
• Insertion and Ongoing Care of Peripheral Venous Cannulae
• Insertion and Ongoing Care of Indwelling Urinary Catheters
These audits continue to be repeated. The initial audits identified good overall compliance to best
practice standards and actions were planned and implemented to ensure full compliance was
achieved. Audits for the last three quarters have demonstrated 100% compliance with all standards
relating to the above high impact interventions.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the
cleanliness of our facilities highly.
Patient Satisfaction - Cleanliness as %
100
91
80
90
63
63
Overall
Satisfaction
Very Good &
Excellent
60
40
20
0
Room
Bathroom
1.2 Patient Led Assessment of the Care Environment [PLACE]
PLACE is an annual assessment of inpatient healthcare sites in England, led by patient
representatives, and it is a benchmarking tool to ensure that improvements are made in non-clinical
aspects of patient care, including the environment, food, privacy and dignity. It was introduced in
2013 and replaced the old Patient Environment Action Team [PEAT] inspections.
The assessment involves patients and staff who assess the hospital and how the environment
supports patient 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 jobs.
The results show how hospitals are performing locally and national. The results from PLACE for BMI
Chelsfield Park Hospital are shown below.
Cleanliness
94.67%
Food
95.51%
Privacy, Dignity & Wellbeing
92.5%
Condition, Appearance & Maintenance
92.08%
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 Chelsfield Park Hospital. BMI Healthcare won the Best VTE
Education Initiative Award category of the Lifeblood VTE Awards 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 assess every patient and the results of our audit on this
has shown that 100% of NHS funded patients had VTE Risk Assessments completed on admission.
BMI Chelsfield Park Hospital reports the incidence of 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.
BMI Chelsfield Park Hospital has a VTE incidence of 0.02 per 100 admissions.
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.
BMI Chelsfield Park Hospital has participated in the PROMs programme since 2012 but no results
data has been produced for the hospital due to low patient numbers.
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, and 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 Optimising the patient prior to admission – i.e. Hb optimization, 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 mobilization
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
BMI Chelsfield Park Hospital has a multi-disciplinary team which reviews progress and
implementation of clinical pathways. Average length of stay for patients undergoing Total Hip
Replacement is 3.3 days and Total Knee Replacement 3.6 days.
The success of ERP has mainly been due to a focus on patient assessment, education and active
participation from pre-admission to discharge.
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.
BMI Chelsfield Park Hospital’s rate for unplanned readmissions within 31 days of surgery is 0.219
per 100 discharges and return to theatre is 0.2 per 100 theatre cases. These rates compare very
favourably to overall BMI Healthcare rates and those of NHS hospitals.
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.
Levels of patientsatisfaction are summarised in the table below to compare changes between 2012
and 2013.
2012
2013
Nursing
98.2%
97.3%
Accommodation
91.5%
90.6%
Admission
92.8%
92.4%
Catering
93.1%
92.03%
Discharge
91.7%
91.9%
Overall Quality of Care
98.8%
98.1%
N/A
99%
Recommendation to Friends &
Family
A multi-disciplinary group meets each month to review the latest patient satisfaction results and
identify areas of focus for improvement.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Chelsfield Park 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.
During 2013 BMI Chelsfield Park Hospital received 0.551 written complaints per 100 admissions,
this is less than the average for BMI Healthcare. Complaint trends are summarised below.
Complaint Type
Number
Consultant Care
11
Nursing Care
5
Financial
14
Clinical Treatment
3
Appointment Delay
2
Test Result Delay
2
Administration
1
Confidentiality
1
TOTAL
39
Complaints escalated to Stage 2 – Corporate Resolution
1
Complaints escalated to Stage 3 – Independent Adjudication
0
Complaints involving staff and Consultants are addressed directly with them in order to provide a full
response to issues raised by patients. The highest number of complaints related to Consultant Care,
however, there were no specific Consultants highlighted through trend analysis.
4. CQUINS
The CQUINS set by NHS London for the Standard Acute Contract for 2013/2014 are detailed in the
table below.
CQUIN
ACHIEVED
VTE Risk Assessment
100%
Response rate to Friends & Family Test [Target 15%]
39%
Completion and submission of Safety Thermometer
100%
% of New Outpatients questioned regarding smoking, and given appropriate
information about local smoking cessation services.
100%
Use of best practice in urinary catheter care
100%
Nutritional Assessment
100%
5. National Clinical Audits
BMI Chelsfield Park Hospital continues to participate in National Joint Registry audit and data from
all joint replacements are submitted to this.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
Static MRI Scanner
The hospital started providing MRI services in April 2013 with a high specification mobile MRI
scanner and plans are being drawn up for the hospital to have its own static MRI scanner.
Refurbishment
A major refurbishment project is planned to commence in the summer of 2014 with anticipated
completion in early 2015. This major investment and project will result in an improved, modernized
main reception, waiting areas, Assisted Conception Unit and Out-Patient Department which will
improve the experience of patients attending the hospital and staff working in the hospital.
The refurbishment will also lead to the improvement of some in-patient rooms and will be taking
place in conjunction with ongoing redecoration and improvement of clinical areas not directly
affected by the refurbishment project.
8. Mandatory Quality Indicators
Summary hospital-level mortality indicator [SHMI] data for BMI Chelsfield Park Hospital will not be
available until October 2014.
9. Non-Mandatory Quality Indicators
The percentage of patients who received care as in-patients who would recommend BMI Chelsfield
Park Hospital as a provider of care to their family and friends is 99%. This data is collected and
reported through the Patient Satisfaction Questionnaire that is given to all patients at the hospital
and is from a 39% response rate.