CEO STATEMENT
BMI Foscote 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 Today that work has been superseded by the Private Hospitals Information Network which is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
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Hospital Information
BMI The Foscote Hospital in Banbury, Oxfordshire is managed by BMI Healthcare, Britain's
leading provider of independent healthcare with a nationwide network of hospitals & clinics The
Hospital is a Charitable Trust and has 12 beds with all rooms offering the privacy and comfort of
en-suite facilities, televisions, wifi and telephone. It also has an operating theatre and separate
endoscopy suite .35% of the patients at The BMI Foscote Hospital during the reportable period
were NHS patients.
The BMI Foscote Hospital has added to its specialties this past year by introducing ENT as an
Out Patient facility investing in a new diagnostic microscope, Endoscopic equipment and also
audiometry testing equipment in order to offer a one stop clinic to its patients.
This specialist expertise is supported by caring and professional medical staff, with dedicated
nursing teams and Resident Medical Officers on duty 24 hours a day, providing care within a
friendly and comfortable environment.
Recent Refurbishment
During the reportable period the Hospital has undergone a complete refurbishment and upgrade
of its Radiology department, consisting of new Digital x-ray equipment and also a new separate
ultra sound department and equipment.
In February 2014 the Hospital also underwent an upgrade of its fire defense systems with
replacement fire doors and upgrades to its roof space compartmentalization.
The next phase to the Hospitals refurbishment is to
upgrade and refurbish patient’s rooms to include wet
floor shower rooms and the replacement of carpets
within these areas with new easy-to-clean flooring as
well as clinical hand washing sinks in those rooms which
presently have none.
BMI Healthcare are registered as a provider with the
Care Quality Commission (CQC) under the Health &
Social Care Act 2008. BMI The Foscote Hospital is registered as a location for the following
regulated services:•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
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The CQC carried out an unannounced inspection on the 11th June 2013 and found:
Standards of treating people with respect and involving them in their care
Met this standard
Standards of providing care, treatment & support which meets people's needs
Met this standard
Standards of caring for people safely & protecting them from harm
Met this standard
Standards of staffing
Met this standard
Standards of management
Met this standard
The BMI Foscote 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 hospital’s Medical Advisory Committee. The Medical Advisory Committee (MAC) is
made up of selected consultant users representing a variety of specialties. Membership are by
invitation from the Executive Director and the Trustees. The Executive Director and the Director
of Nursing also attend the meetings where the main functions of the MAC are as follows:
•
To support the Executive Director in delivering the hospital strategy on Clinical
Governance. The hospitals Clinical Governance Group will report to each MAC
meeting on progress and consults with the MAC on the continued development of
Clinical Governance.
•
To keep under review the hospitals strategy for Clinical Quality. The Director of
Nursing will report on progress and take advice from the MAC on future development.
•
To review local clinical outcome data, advising the Executive Director of the findings
and any recommended action.
•
Support the development of good practice standards or clinical guidelines and multidisciplinary care pathways, based on national/evidence-based guidelines.
•
Agree priorities and protocols for clinical audit and outcome measurements. Support
and facilitate regular clinical audit in each specialty and disseminate written records of
such audit within each specialty and to the designated Consultant.
•
Advise the Executive Director on practice privileges, having reviewed individual
applications with regard to compliance with the Hospital policy on practicing privileges.
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Regional Clinical Quality Assurance 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, standardised information to the NHS, including coding of procedures,
diagnoses, co-morbidities and PROMs (Patient Reported Outcome Measures) for NHS
patients.There are additional external reporting requirements for Care Quality
Commission(CQC), Public Health England (Previously HPA) CCGs ( Clinical Commissioning
Group) 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 The BMI
Foscote Hospital.
We have had: • Zero cases of MRSA bacteraemia in the last year (NHS 1.17cases/100,000 bed days).
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• Zero cases MSSA bacteraemia cases /100,000 bed days
• Zero cases E.coli bacteraemia cases/ 100,000 bed days
• Zero 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
o Knees
0%
2.85% (1out of 35 patients)
Infection Prevention and Control (IPC) environmental and clinical practice audits are carried out
within all departments of the hospital in accordance to an annual audit schedule, devised by the
Corporate IPC team and in accordance with BMI IPC pol16. These are performed using the
Infection Prevention Society’s (IPS) Quality Improvement Tools (QIT) and Care Bundles.
QIT audit results are reviewed by the IPC team and areas of concern are re-visited at more
regular intervals with action plans being devised for desired improvements.
Challenges presented by the general hospital environment throughout the QIT audits have now
been assessed and an action plan to address the areas of improvement has been published.
This will include the refurbishment of patient rooms with the replacement of carpets with easyto-clean flooring and the implementation of clinical hand washing sinks in those rooms without
any. The refurbishment will incorporate extensive local involvement by the IPC team and
Microbiologist from the planning stage to completion of the first phase ensuring that clinical
environments are fit for purpose.
Changes to clinical practice have been implemented as a direct result of the QIT audits. These
changes have been based on risk assessment, widespread clinical and non-clinical education
from the IPC team, controlled change management and effective communication.
On re-audit of the areas of concern highlighted in the QIT schedule, qualitative and quantitative
improvements in clinical practice and environment have been recorded, and reported by the IPC
team. Overall clinical knowledge regarding IPC, prevention of HCAIs (Healthcare Associated
Infections) and reduction of the risk of cross contamination has improved throughout the
hospital.
High Impact Intervention (HII) care bundles for peripheral cannulas, urinary catheters, and
Surgical Site Infection (SSI) have been completed throughout the reportable period. The base
line audit results for The Foscote hospital provided results as following:
Urinary Catheters
Insertion:
Ongoing care:
100%
100%
Peripheral Cannula
Insertion:
95%
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SSI
Ongoing care:
100%
Pre-operative
Intra-operative
Post-operative
100%
100%
100%
All care bundles are re-audited monthly by the IPC team and results have fluctuated minimally
from the baseline.
Ongoing education is provided by the IPC team nationally and locally in order to continually
improve upon the HII audits. This training is delivered as part of the mandatory eLearning and
also in practical training sessions. Practical training in IPC includes Hand Hygiene and ANTT
(Aseptic Non Touch Technique) with competencies to be assessed and met, by all attending
clinical staff to ensure that a standardised high level of competency is achieved by all.
Despite the scoring for peripheral cannula insertion being 95% there has been only 1 case of
peripheral cannula associated phlebitis in the last 12 months.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
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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 (Patient Led Assessment of the Care Environment), 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 of the hospital
showed that we were achieving the high standards of cleanliness we aspire to and, that our
patients felt that we treated them with dignity whilst maintaining their privacy. In regards to food
at the Foscote although we have achieved a Platinum award and a 5 star rating the audit found
that the choices were limited and repetitive. During this reportable year we have begun working
towards changing our menu’s to include more choice with an emphasis on nutrition and
wellbeing. The menus are in the process of being reviewed by a dietician together with the
Hospitals Catering Manager to ensure all specialised diets are catered for. This review also
includes nutritional advice to pre-operative patients as part of our Enhanced Recovery Program
to ensure that our patients are in their optimal nutritional state prior to surgery.
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Other actions taken from this audit were in regards to patient safety in the hospital grounds. The
patient auditors felt that there was a need for a public pathway from the lower hospital car park
to the main reception doors. This was put into place along with safety posts to prevent vehicles
mounting the curb. Larger signage for the patient toilet facilities was recommended and this has
now been added to aid those of our patients with sight impairment.
1.2 Patient Led Assessment of the Care Environment (PLACE)
Cleanliness
99.10%
Food
91.8%
Privacy, Dignity and Wellbeing
96.88%
Condition Appearance
96.88%
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, The BMI Foscote 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 on every patient who is admitted to
our facility and the results of our audit on this have shown a compliance rate of 100%. To
ensure that this standard is sustained we will continue to be audited monthly throughout the
year and discuss at the monthly clinical governance meeting.
The BMI Foscote 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.
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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 The BMI Foscote Hospital
Oxford Hip Score average
2013/14
BMI Foscote
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
15.889
42.778
26.889
17.907
39.224
21.317
England
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'
Oxford Knee Score average
2013/2014
BMI Foscote
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
N/A
N/A
Suppressed due to low numbers.
18.893
34.902
16.01
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
2.2 Enhanced Recovery Programme (ERP)
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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 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 BMI Foscote Hospital set up a steering committee to develop a robust and comprehensive
ERP pathway for our patients. The Committee is comprised of the Executive Director, Director
of Nursing, Pre-Operative Assessment Manager, Consultant Orthopaedic Surgeon and MAC
Chair, Consultant Anesthetist and MAC representative, Physiotherapy Manager, Ward Manager
and Theatre Manager.
The Group was set up to plan the patient’s pathway from Pre assessment to discharge and
beyond to ensure that our patients are well prepared and in their best optimum state prior to
surgery to ensure the best outcome for them.
Working with a dietician a patient advice leaflet is being developed to be given out at preoperative assessment with advice on the best food group choices to aid recovery. Carbohydrate
loading is also being considered for patients who are to have surgery lasting over 2 hours.
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Post-operative menu’s whilst still in hospital are also being reviewed to ensure that our patients
are being given the correct nutritional requirements to further aid wound healing and also to
ensure the wellbeing of our patients.
Pain relief has been reviewed by the Anaesthetic department under the leadership of the
Anaesthetic MAC representative. This is to ensure that adequate pain relief is maintained so
enabling the early ambulation of our patients. Local anaesthetic infiltration is now being
administered prior to suturing joint replacements by the Orthopaedic Surgeon’s; this has aided
the Physiotherapists to ambulate the patients earlier than previously due to the improved
management of the patients pain.
The Physiotherapy department along with the Pre-operative Assessment Manager have written
a comprehensive patient booklet for patients undergoing Total Hip Replacement and Total
Knee replacement. The booklet explains the pathway from the booking of the surgery to
discharge and beyond. Both booklets are under review by the ERP steering Group and BMI
Quality and Risk Leads. We are hopeful that the Knee booklet will be available to our patients
by the end of June 2014 and the Hip booklet soon after that. The plan is for other similar
booklets to be produced for Gynaecology and General Surgery by the end of 2014.
Hip and Knee replacement patients are now all seen by a member of the Physiotherapy team at
pre-operative assessment when advice on exercises both pre-operative and post procedure are
discussed and practiced. Advice is also given at this time by the physiotherapy department on
home requirements and dependent on the outcome from this meeting any equipment required is
also allocated to the patient at this time. This enables the patient and their families to prepare
for discharge and helps to promote earlier independence whilst maintaining the safety of the
patient.
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.
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As can be seen from the graph there has been a small increase within the reportable period of
both readmissions and return to theatre for a percentage of our patients. At the Foscote we
strive to ensure the very best possible outcome for our patients. When this is not achieved, a
comprehensive investigation is carried out (Root Cause Analysis) following BMI robust policy to
identify any contributing causes and subsequent learning opportunities. The incidents are
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recorded within the BMI sentinel governance system and the findings and actions taken are
discussed at the Foscote Hospitals Clinical Governance Committee meeting and presented at
MAC for further discussion by the Hospitals consultants.
3. Patient experience
3.1 Patient satisfaction
BMI Healthcare is committed to providing the highest levels of quality of care to all of our
patients. We continually monitor how we are performing by asking patients to complete a patient
satisfaction questionnaire. Patient satisfaction surveys are administered by an independent third
party.
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Delivering a high quality of care of our patients is important to all of the staff at the BMI Foscote
Hospital and is very much a team effort. The Foscotes Quality Committee was set up in 2012
and is made up of representatives from all areas of the hospital. The Committee meets every
month and reviews the latest patient satisfaction results. This has helped the hospital to focus
on what we do well and what we can improve on to enhance the patient journey during their
time with us.
During the time this committee has been running there has been a significant improvement in
the Patient Satisfaction results. Presently we are 1st in the region and in the Company and have
consistantly been in the top 10 within past 6 months. The challenge going forward is to keep at
the top. This is a challenge we as a hospital embrace, as the satisfaction of good care is not
only reserved for the patient, the hospital staff feel a real sence of achievement when the results
reflect the effort and passion they put into the care they give.
The BMI Foscote Hospital also has had 27 reviews posted on the NHS Choices site with an
overall rating of 5 stars which is something we are very proud off.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Foscote 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.
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It should be noted that the complaint process does not allow for compensation, although
realistic and appropriate goodwill gestures will be made where it can be shown that the patient
has received sub-optimal clinical care. A small proportion of complaints will escalate to stage
two, this is only when every effort has been made to resolve the concerns at stage 1, local
resolution. It should be stressed that of recent stage two complaints reviewed, our original
response has been upheld in the majority of cases.
There have not been any reported complaints which have escalated to stage 3 within the
timeframe 1.4.13 to 31.3.14. The numbers of complaints which are also a reported clinical
incident are relatively low.
A number of the complaints are regarding financial issues, both in terms of hospital costs and
the financial systems in place, along with Consultant fees. It is however pleasing to report that
complaints against hospital care delivery remains low.
Good communication has been developed by staff investigating complaints and feedback on
patient experience ie. communication to improve the service. Information is now available to
patients particularly in the outpatient areas, informing of the likelihood of hospital charges in
addition to Consultants fees.
There has also been a slight increase in complaints against Consultants. These are
predominantly around surgical outcome and communication. Consultant complaints are
investigated with the aid of all parties involved and discussed through the MAC. Consultants are
advised of the changing attitude to the Consultant/patient relationship
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4 CQUINS
Goal
Goal Name
Number
1
Friends and
Family Test
2
3
NHS Safety
Thermometer
Dementia
4
VTE
5
Care Bundle
Audits,
Catheters
Post-Surgical
Remote
Follow Up
6
7
Health
Promotion
Description of
Goal
Goal
Weighting (%
of CQUIN
scheme
available)
To improve the
16.6%
experience of
patients in line with
Domain 4 of the
NHS Outcome
Framework
To reduce harm.
16.6%
To incentivise the
identification of
patients with
dementia
To reduce
avoidable death,
disability and
chronic ill health
from venous
thromboembolism
To demonstrate
quality perioperative care
Digital First, to
reduce
unnecessary face
to face
appointments
To support healthy
lifestyles and
making every
contact count.
Totals:
Quality Domain
(Safety,
Effectiveness,
Patient
Experience or
Innovation)
Patient
Experience
Safety
0%
16.6%
Safety
16.6%
Safety
16.6%
Innovation
16.6%
Effectiveness
100%
4. National Clinical Audits
The BMI Foscote 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.
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Research
No NHS patients were recruited to take part in research.
5. Priorities for service development and improvement
•
•
•
•
Development of ERP to include patient booklet for Total hip Replacement, Total Knee
Replacement, General Surgery and Gynaecology.
Improvement of the Out Patients Department with the introduction of a further
Consultation room and patient treatment room.
With the new Radiology facilities and the recruitment of a new Radiologist we are looking
at introducing new services including interventional diagnostics.
ENT which we has now been introduced within the out patients department is being
considered as a new surgical day case specialty in the coming 12 months.
6. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the The
BMI Foscote Hospital for the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Oct 11 – Jun 13
National
Average
1.0006
Highest National
Score
1.1822
Lowest National
Score
0.6735
The BMI Foscote Hospital considers that this data is as described for the following reasons:
The patients the BMI Foscote care for are in the majority elective minor surgical patients with a
small percentage of medical patients and patients requiring convalescence.
There is a strict admission criteria that we work to which includes only accepting patients with
an ASA of either 1 or 2. This criterion makes our patients relatively low risk for surgery and as
such contributes to our mortality rate being zero.
The BMI Foscote Hospital intends to continue with the same admission criteria in the coming 12
months in order to sustain our low rate.
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8.2 The BMI Foscote Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.204
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
0.083
Highest National
Score
0.157
Lowest National
Score
0.014
The BMI Foscote Hospital considers that this data is as described for the following reasons:
Advising patients that moderate activity is beneficial and it is important that they continue to
undertake all activities of daily living.
Advising patients that it is important they continue with physiotherapy following surgery to
enhance their recovery.
(ii) Varicose vein surgery
Unit
Not
available
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
-8.738
Highest National
Score
8.172
Lowest National
Score
-15.918
No data available.
The Foscote Hospital does not currently undertake NHS patients in this category
(iii) Hip replacement surgery
Unit
26.889
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
21.280
Highest National
Score
24.684
Lowest National
Score
17.214
The BMI Foscote Hospital considers that this data is as described for the following reasons:
Advising patients that moderate activity is beneficial and it is important that they continue to
undertake all activities of daily living.
Advising patients that it is important they continue with physiotherapy following surgery to
enhance their recovery.
To roll out the patient physiotherapy and nutrition advice booklet pre operatively to ensure that
the patients are well informed/prepared and in their optimum state of health prior to their surgery
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(iv) Knee replacement surgery during the reporting period.
Unit
Not
Available
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
15.99
Highest National
Score
20.37
Lowest National
Score
12.2
No data available.
The BMI Foscote Hospital considers that this data is as described for the following reasons .
Less than 30 patients going through the process, meaning the site cannot be scored.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
BMI Foscote Hospital within 28 days of being discharged from a hospital which forms part of the
hospital during the reporting period.
Unit
Not
applicable
Reporting Periods
(at least last two
reporting periods)
Apr 11 – Mar 12
National
Average
11.45
Highest National
Score
14.35
Lowest National
Score
7.96
The BMI Foscote Hospital does not treat patients within this age group.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the BMI Foscote Hospital within 28 days of being discharged from a hospital which forms part
of the hospital during the reporting period.
Unit
0.069%
Reporting Periods
(at least last two
reporting periods)
Apr 11 – Mar 12
National
Average
10.01
Highest National
Score
14.51
Lowest National
Score
5.54
The BMI Foscote Hospital considers that this data is as described for the following reasons:
The BMI Foscote Hospital has taken the following actions to improve this percentage, and so
the quality of its services, by:
Conducting root and branch analysis of factors which contributed to readmission to further
reduce the percentage
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8.4 The BMI Foscote Hospital responsiveness to the personal needs of its patients during the
reporting period.
Unit
95.56%
Reporting Periods
(at least last two
reporting periods)
2012 - 2013
National
Average
68.1
Highest National
Score
84.4
Lowest National
Score
57.4
The BMI Foscote Hospital the following actions to improve this percentage and so the quality of
its services, by:
Continuing to monitor all patient feedback through quality meetings and actions are put
in place to improve all patient quality of care by addressing key issues.
8.5 The percentage of patients who were admitted to BMI Foscote Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
100%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
96
Highest National
Score
100
Lowest National
Score
79
The BMI Foscote Hospital considers that this data is as described for the following reasons:
All clinical staff are aware of the Policy and procedure for capturing patients VTE risk
assessment at all stages of their admission. Audits of medical records are completed monthly
with one of the audits being VTE assessment. There is a quarterly VTE corporate audit that the
BMI Foscote takes part in and the results are shared with the staff and Clinical Governance
Committee.
The BMI Foscote Hospital has taken the following actions to improve this percentage and so the
quality of its services, by auctioning all areas of improvement as a result of both the corporate
and internal audits. The actions are then followed up to ensure completion within a timely
manner at the Clinical Governance Committee meeting with the results reported to MAC.
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8.6 The rate per 100,000 bed days of cases of C. difficile infection reported within the BMI
Foscote Hospital amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
17.3
Highest National
Score
30.8
Lowest National
Score
0
The BMI Foscote Hospital considers that this data is as described for the following reasons:
The monitoring of prescribing antibiotics by the newly recruited Pharmacist.
Patients are rarely transferred from other healthcare establishments.
Patients who are admitted to the hospital are usually done so for elective surgery and are
relatively fit and healthy people all of which reduces the risk significantly to C.difficile.
The BMI Foscote Hospital intends to take the following actions to maintain this score, and so the
quality of its services, by continuing to monitor the above.
8.7 The number and, where available, rate of patient safety incidents reported within the BMI
Foscote 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
40
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
44.55
Highest National
Score
1,810
Lowest National
Score
0
BMI The Foscote Hospital considers that this data is as described.
The Foscote Hospital has taken the following actions to improve this number and so the quality
of its services:
Reviewed the protocols for the clinical staff to refer to when a patient’s condition is deteriorating
following surgery.
Implementation of the ‘SBAR’ assessment tool within the clinical areas to monitor significant
changes in a patient’s condition.
Compile an ‘emergency pack’ for equipment that might be required in case of a patient’s
condition deteriorating.
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Rate of patient safety incidents reported
Unit
3.077
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
7.76
Highest National
Score
30.95
Lowest National
Score
1.68
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
0.64
Highest National
Score
28
Lowest National
Score
0
Percentage of patient safety incidents that resulted in severe harm or death
Unit
0%
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
0.9
Highest National
Score
2.9
Lowest National
Score
0.0
8.8 The percentage of staff employed by the BMI Foscote Hospital during the reporting period,
who would recommend the BMI Foscote Hospital as a provider of care to their family or friends.
Unit
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
64.58
Highest National
Score
96.43
Lowest National
Score
33.73
Not
available
BMI The Foscote Hospital considers that this data is as described:
This year The BMI Foscote Hospital was excluded from the BMI Healthcare Staff satisfaction
survey.
BMI The Foscote Hospital has taken the following actions to improve this percentage:
Engaging with staff through staff forums.
Improving communication with regular departmental meetings.
Introduction of daily ‘huddles’ to discuss all issues/potentials issues from each department
within the hospital.
Planned introduction of a Foscote staff survey for the next reportable period.
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7. 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 Foscote Hospital as a provider of care to
their family or friends.
Unit
86.72%
Reporting Periods
(at least last two
reporting periods)
Jun 13 – Jan 14
National
Average
66.23
Highest National
Score
94.38
Lowest National
Score
35.63
The BMI Foscote Hospital considers that this data is as described for the following reasons;
The “Friends and Family” question is positioned on the Patient questionnaire in such a way as
can be easily missed. Going forward the hospital is to work alongside its new Management
Team to develop a new questionnaire and the Friends and family question will be more
prominent.
The ongoing work continues lead by the hospitals Quality Committee to improve the patient
experience and so the quality of its services at The BMI Foscote Hospital.
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