BMI.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 Today that work has been superseded by the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
Hospital Information
‘••ƒŽŽ‘•’‹–ƒŽ
BMI Ross Hall Hospital in Glasgow is part of BMI Healthcare, Britain's leading provider of
independent healthcare with a nationwide network of hospitals & clinics performing more
complex surgery than any other private healthcare provider in the country. Our commitment is to
quality and value, providing facilities for advanced surgical procedures together with friendly,
professional care.
BMI Ross Hall Hospital has 101 beds with all rooms offering the privacy and comfort of en-suite
facilities, satellite TV and telephone. The hospital has four theatres, one minor procedures
theatre, five bed intensive care unit and a high dependency unit.
These facilities combined with the latest in technology and on-site support services, enable our
consultants to undertake a wide range of procedures from routine investigations to complex
surgery. 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.
BMI Ross Hall Hospital is registered as a location for the following regulated services:•
•
•
•
•
Treatment of disease, disorder and injury
A full range of medical and surgical healthcare procedures
Diagnostics and screening
Provision of 24 hour nursing care
Treatment of children over 3 years old on a daycase and overnight basis.
Healthcare improvement Scotland regulate the service and do a minimum of one unannounced
inspection every 2 years
The last Healthcare Improvement Scotland unannounced inspection was on 6th and 7th
May2013.
The inspectors from Healthcare Improvement Scotland check independent
healthcare services regularly to make sure that they are complying with necessary standards
and regulation. They inspected on 5 Quality themes with the following results
Theme0
Theme 1
Theme 2
Theme 3
Theme 4
leadership
Quality of Information
Quality of care and support
Quality of environment
Quality of staffing
Quality of management and
5 Very good
5 very good
4 Good
5 Very good
5 Very good
Ross Hall 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.
There are external reporting requirements for Healthcare Improvement Scotland, Health
Protection Scotland and the Insurers. There has also been ongoing progress on the project to
collect and publish comparative data to assist patients and referrers with their choices on
healthcare facility. This has started with the launch of an independent Private Healthcare
Information Network websiteŚƚƚƉ͗ͬͬǁǁǁ͘ƉŚŝŶ͘ŽƌŐ͘ƵŬ This provides information on facilities,
numbers of a variety of procedures carried out at each site and some basic quality indicators.
The range of the available indicators will continue to grow for ongoing enhancement of choice.
1. Safety
1.1 Infection prevention and control
The focus on infection prevention and control continues under
the leadership of the Group Head of Infection Prevention and
Control, in liaison with the link nurse in Ross Hall Hospital
We have had: • Zero cases of MRSA bacteraemia in the last year (Zero
cases of MSSA bacteraemia in the last year
• Zero cases of hospital apportioned Clostridium difficile in
the last 12 months
• SSI data is also collected and submitted to Health Protection Scotland for orthopaedic
surgical procedures .
• Our infection rates are:Hip arthroplasty
Knee arthroplasty
zero
zero
There are regular Infection Prevention and Control audits including surgical site surveillance,
environmental and safe disposal of sharps and clinical waste .
We have replaced all the wash hand basins in clinical room in the last 12 months and are
replacing the floors and work tops in the clinical rooms
Ross Hall Hospital takes Infection Prevention and Control very seriously and has an infection
prevention and control lead nurse who is a resource for staff and patients and ensures
compliance with National Standards. Because best practice constantly evolves, so too do our
policies and procedures on Infection Prevention and Control. The hospital has a very good
relationship with Health Protection Scotland.
The Corporate Head of Infection Prevention and Control liaises with each hospital’s infection
control team on a regular basis to ensure the implementation of evidence based principles and
practice. In addition every member of staff receives update training annually. All these activities
combine to monitor and maintain our excellent results.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
1.2 Venous Thrombo-embolism (VTE)
BMI Healthcare, holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including, Ross Hall 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 Structure category.
We see this as an important initiative to further assure patient safety and care. We audit our
compliance with our requirement to VTE risk assessment every patient and the results of our
audit on this has shown 92% compliance. We have an appointed lead in VTE compliance who is
responsible for compliance.
Ross Hall 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.
PE (Rate per 100 admissions)
Ϭ͘Ϭϭ
Ϭ͘ϬϬϴ
Ϭ
Ϭ͘ϬϬϮ
Ϭ͘ϬϬϲ
Ϭ͘ϬϬϲ
Ϭ͘ϬϬϰ
Ϭ͘ϬϬϴ
Ϭ͘Ϭϭ
Ϭ͘ϬϬϮ
Ϭ͘ϬϭϮ
Ϭ
ϮϬϬϵ
ϮϬϭϬ
ϮϬϭϭ
ϮϬϭϮ
ϮϬϭϯ
ϮϬϭϰ
2.0 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:•
•
•
patients are in the optimal condition for treatment
patients have different care during their operation
patients experience optimal post-operative rehabilitation.
2.1 Enhanced Recovery Programme (ERP)
The ERP is about improving patient outcomes and speeding up a patient’s recovery after
surgery. ERP focuses on making sure patients are active participants in their own recovery and
always receive evidence based care at the right time. It is often referred to as rapid recovery, is
a new, evidence-based model of care that creates fitter patients who recover faster from major
surgery. It is the modern way for treating patients where day surgery is not appropriate.
ERP is based on the following principles:1. All Patients are on a pathway of care
a. Following best practice models of evidenced based care
b. Reduced length of stay
2. Patient Preparation
a. Pre Admission assessment undertaken
b. Group Education sessions
c. Optimizing the patient prior to admission – i.e HB optimisation, control comorbidities, medication assessment – stopping medication plan.
d. Commencement of discharge planning
3. Proactive patient management
a. Maintaining good pre-operative hydration
b. Minimising the risk of post-operative nausea and vomiting
c. Maintaining normothermia pre and post operatively
d. Early mobilisation
4. Encouraging patients have an active role in their recovery
a.
Participate in the decision making process prior to surgery
b.
Education of patient and family
c. Setting own goals daily
d. Participate in their discharge planning
At Ross Hall we continue to embed the principles of the Enhanced Recovery Programme with
collaborative working with our consultants and physiotherapy team as well as our nursing
teams. Year to date average length of stay for Total Hip Replacements is4.9 nights and for
Total Knee Replacement 4.8 nights . Our corporate Integrated Care Manager analyses and
reports site compliance on these results monthly.
ǀĞƌĂŐĞ>ĞŶŐƚŚŽĨ^ƚĂLJ
Ϯ͘ϱϬϬ
Ϯ͘ϰϱϴϭ
Ϯ͘ϰϬϬ
Ϯ͘ϯϮϮϭ
Ϯ͘ϯϬϬ
Ϯ͘ϮϱϮϴ
ϮϬϬϵ
Ϯ͘ϮϮϰϯ
ϮϬϭϬ
Ϯ͘ϮϬϬ
Ϯ͘Ϭϵϵϱ
Ϯ͘ϭϬϬ
Ϯ͘ϬϳϬϯ
ϮϬϭϭ
ϮϬϭϮ
Ϯ͘ϬϬϬ
ϮϬϭϯ
ϮϬϭϰ
ϭ͘ϵϬϬ
ϮϬϭϰ
ϮϬϭϯ
ϮϬϭϮ
ϮϬϭϭ
ϮϬϭϬ
ϮϬϬϵ
ϭ͘ϴϬϬ
3.0. Unplanned Readmissions within 31 days and unplanned returns to theatre.
Unplanned readmissions normally due to a clinical complication related to the original surgery.
Patients can be readmitted at any time of day under the care of their consultant as long as it is
clinically safe.
Unplanned Readmissions within 31 days and unplanned returns to theatre
Ϭ͘Ϭϲ
Ϭ͘Ϭϱ
Ϭ
Ϭ͘Ϭϰ
Ϭ͘Ϭϭ
Ϭ͘ϬϮ
Ϭ͘Ϭϯ
Ϭ͘Ϭϯ
Ϭ͘ϬϮ
Ϭ͘Ϭϰ
Ϭ͘Ϭϱ
Ϭ͘Ϭϭ
Ϭ͘Ϭϲ
Ϭ
ϮϬϬϵ
ϮϬϭϬ
ϮϬϭϭ
ϮϬϭϮ
ϮϬϭϯ
ϮϬϭϰ
Unplanned return to theatre (rate per 100 theatre cases)
Ϭ͘Ϭϴ
Ϭ
Ϭ͘Ϭϳ
Ϭ͘Ϭϭ
Ϭ͘Ϭϲ
Ϭ͘ϬϮ
Ϭ͘Ϭϱ
Ϭ͘Ϭϯ
Ϭ͘Ϭϰ
Ϭ͘Ϭϰ
Ϭ͘Ϭϯ
Ϭ͘Ϭϱ
Ϭ͘ϬϮ
Ϭ͘Ϭϲ
Ϭ͘Ϭϭ
Ϭ͘Ϭϳ
Ϭ
ϮϬϬϵ
ϮϬϭϬ
ϮϬϭϭ
ϮϬϭϮ
ϮϬϭϯ
ϮϬϭϰ
Ϭ͘Ϭϴ
Unplanned returns to theatre are due to clinical complications. We have a 24 hour on call rota
for theatre, laboratory and imaging so complications can be managed at any times
Clinical Incidents
All clinical incidents are reported on Sentinel, the risk management system.
The incidents are reviewed at the Clinical Governance meeting and are discussed at the
Medical Advisory Committee.
As part of the process of reporting clinical incidents the hospital team ensures that lessons are
learned to minimize recurrence of the incident.
^ĞƌŝŽƵƐ/ŶĐŝĚĞŶƚƐ
ϭ͘ϮϬϬ
ϭ͘ϬϬϬϬ
ϭ͘ϬϬϬ
ϮϬϬϵ
Ϭ͘ϴϬϬ
ϮϬϭϬ
Ϭ͘ϲϬϬ
ϮϬϭϭ
ϮϬϭϮ
Ϭ͘ϰϬϬ
ϮϬϭϯ
ϮϬϭϰ
Ϭ͘ϬϬϬϬ
Ϭ͘ϬϬϬϬ
Ϭ͘ϬϬϬϬ
Ϭ͘ϬϬϬϬ
ϮϬϭϮ
ϮϬϭϯ
ϮϬϭϰ
Ϭ͘ϬϬϬϬ
ϮϬϭϭ
Ϭ͘ϮϬϬ
ϮϬϭϬ
ϮϬϬϵ
Ϭ͘ϬϬϬ
4.0 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.
Views of our service users are actively sought with a patient focus group meeting 3
times per year
4.1 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Ross Hall 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 Healthcare Improvement Scotland if they are not
satisfied with the outcome at the other 2 stages or at any time.
At any time service users can contact Health Improvement Scotland at Healthcare Improvement
Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB
The graph below includes any verbal complaints or comments so Ross Hall can ensure that
lessons are learned and action plans are agreed to ensure a better service.
BMI Ross Hall Hospital involves service users in review of service provided. It is important that
we learn from complaints and incidents and identify any themes which can be addressed
5.0 Priorities for service development and improvement
ŶĞǁdƐĐĂŶŶĞƌŝƐƉůĂŶŶĞĚĨŽƌƐƵŵŵĞƌϮϬϭϰǁŚŝĐŚǁŝůůďĞĂϯϮϬƐůŝĐĞƐĐĂŶŶĞƌ͘
ϲ͘ϬCommitment to Education and training
D/ZŽƐƐ,ĂůůƉƌŽǀŝĚĞƐŵĂŶĚĂƚŽƌLJƚƌĂŝŶŝŶŐĨŽƌĂůůƐƚĂĨĨďLJĞůĞĂƌŶŝŶŐĂŶĚĨĂĐĞƚŽĨĂĐĞƚƌĂŝŶŝŶŐ͘
KƉƉŽƌƚƵŶŝƚŝĞƐĞdžŝƐƚĨŽƌƐƚĂĨĨƚŽĚŽWŽƐƚŐƌĂĚƵĂƚĞĚĞŐƌĞĞƐ
^ƉĞĐŝĂůŝƐƚŶƵƌƐĞƐĂĐƚĂƐĂƌĞƐŽƵƌĐĞĨŽƌĂůůƐƚĂĨĨƚŽĞŶƐƵƌĞƵƉƚŽĚĂƚĞĞǀŝĚĞŶĐĞďĂƐĞĚƚƌĞĂƚŵĞŶƚ
ZŽƐƐ,ĂůůƐƵƉƉŽƌƚƐKWƚƌĂŝŶŝŶŐĂŶĚƚŚĞĂƚƌĞƉƌĂĐƚŝƚŝŽŶĞƌĚĞǀĞůŽƉŵĞŶƚ͘
tĞŚĂǀĞĐůŽƐĞůŝŶŬƐǁŝƚŚƚŚĞWƌŝŶĐĞĂŶĚWƌŝŶĐĞƐƐŽĨtĂůĞƐ,ŽƐƉŝĐĞŝŶƚĞƌŵƐŽĨƚƌĂŝŶŝŶŐĂŶĚĚĞǀĞůŽƉŵĞŶƚ
D/ZŽƐƐ,Ăůů,ŽƐƉŝƚĂůĨĂĐŝůŝƚĂƚĞƐWƐĞƐƐŝŽŶƐĨŽƌ'WƐ͘