BMI Shirley Oaks 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 Today that work has been superseded by the Private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
BMI Shirley Oaks Hospital is a 50 bedded, built for purpose facility on the edge of Croydon, South West
London. The hospital provides care and treatment to patients in a range of specialities, including
Orthopaedic surgery, ENT surgery, Ophthalmic Surgery, General Surgery, Gastroenterology, General
Medicine, Cardiology, Gynaecology, Urology, Fertility Services, Family Planning Services and
Endoscopy. This includes all elements of the patient pathway from Outpatients clinics, through to
specialist treatment or surgery and onward to a safe discharge and follow up. We treat adult patients
throughout the hospital and see children over the age of 3 years within our Outpatient function. Patient
services are supported by Pharmacy, Physiotherapy and Radiology services. Open bore MRI and CT
scanning are available on site.
The hospital has three operating theatres, one of which has ultraclean airflow (laminar flow). Our
Endoscopy Suite is JAG accredited and offers diagnostic services within a discreet unit.
We are an independent provider of healthcare and treat both private and NHS patients. We deliver high
standards of care with low infection rates and high patient satisfaction.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the Health &
Social Care Act 2008. BMI Shirley Oaks Hospital is registered as a location for the following regulated
services:
•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Family Planning
th
The CQC carried out an unannounced inspection on 30 January 2014 and found the following:
Respecting and involving people who use services
Met this standard
Care and welfare of people who use services
Met this standard
Safeguarding people who use services from abuse
Met this standard
Cleanliness and infection control
Met this standard
Management of medicines
Met this standard
Safety and suitability of premises
Met this standard
Requirements related to workers
Met this standard
Staffing
Met this standard
Assessing and monitoring the quality of service
provision
Met this standard
Complaints
Met this standard
The full report can be viewed at http://www.cqc.org.uk/node/297150
BMI Shirley Oaks Hospital has a robust Clinical Governance Structure through which clinical
effectiveness, clinical incidents and clinical quality is monitored and analysed. Where appropriate, action
is taken to improve the quality of care delivered through shared learning structures. There is a clear route
of escalation to the Regional Board and also a cascade so that junior staff and contractors are kept up to
date with current practice.
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 and co-morbidities and PROMs (Patient Reported Outcome Measures) 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,
in liaison with the Infection Prevention and Control Lead at BMI Shirley
Oaks Hospital.
In the last 12 months we have had: •
Zero cases of MRSA bacteraemia in the last year
•
Zero cases of MSSA bacteraemia
•
Zero cases of E. Coli bacteraemia cases
•
Zero cases of hospital apportioned Clostridium difficile
Infection prevention and control audits are completed on a monthly basis and take a different focus each
month. These include hand hygiene, wrist watch compliance and observational audits.
High Impact Intervention Care bundles are audited on a monthly basis including catheter care, peripheral
cannula and isolation and we participate in the monthly Safety Thermometer which focuses on Urinary
Tract Infections, Pressure Ulcers, Falls and Venothromboembolism.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the
cleanliness of our facilities highly. Cleanliness is seen as the responsibility of all staff and clinical and nonclinical teams work together to ensure a consistently high standard.
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 provide motivation for improvement by providing a clear
message, directly from patients, about how the environment or services might be enhanced.
PLACE was introduced in 2013 and 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 show how hospitals are performing nationally and locally.The most recent audit was
rd
undertaken on 3 April 2014. An action plan is in place to rectify the issues found as part of the audit
however the audit results are not yet published.
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 Shirley Oaks. 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 assess every patient who is admitted to our facility on a monthly basis
and the results of our audit on this have shown a consistent 100% compliance.
BMI Shirley Oaks reports the incidence of Venous Thromboembolism (VTE) through the corporate clinical
incident system and root cause analysis is undertaken and any actions learned. 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.
We have had one patient develop a VTE post discharge in the last 12 months. This case was investigated
and all reasonable action had been taken to reduce the patient’s risk both pre and post operatively whilst
in our care as well as upon discharge.
2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Patient Reported Outcome Measures (PROMs) are a means of collecting information on the effectiveness
of specific surgery: groin hernia, knee replacement, hip replacement, varicose veins as perceived by the
patients themselves. PROMS is a Department of Health led programme and patients fill in questionnaires
prior to and after surgery.
Summary of facts for data received for the period April 2011 to March 2012 (published October 2013).
EQ-5D Index (a combination of five key criteria concerning general health)
46.2% of groin hernia respondents recorded an increase in their EQ-5D Index score following their operation
(49.9% in England).
The number of hip replacement questionnaire pairs returned by BMI is suppressed due to small numbers.
66.7% of knee replacement respondents recorded an increase in their EQ-5D Index score following their
operation (78.4% in England).
No varicose vein completed questionnaire pairs have been returned by BMI - SHIRLEY OAKS HOSPITAL
for this measure.
EQ VAS (current state of the patients general health marked on a visual analogue scale)
50.0% of groin hernia respondents recorded an increase in their EQ VAS score following their operation
(38.9% in England).
The number of hip replacement questionnaire pairs returned by BMI - SHIRLEY OAKS HOSPITAL
is suppressed due to small numbers.
42.9% of knee replacement respondents recorded an increase in their EQ VAS score following their
operation (53.8% in England).
No varicose vein completed questionnaire pairs have been returned by BMI - SHIRLEY OAKS HOSPITAL
for this measure.
Condition Specific Measures (a series of questions specific to the patient’s condition)
The number of hip replacement questionnaire pairs returned by BMI - SHIRLEY OAKS HOSPITAL is
suppressed due to small numbers.
75.0% of Oxford Knee Score respondents recorded joint related improvements following their operation
(91.6% in England).
No varicose vein completed questionnaire pairs have been returned by BMI - SHIRLEY OAKS HOSPITAL
for this measure.
Participation and Coverage
There were 90 eligible hospital episodes and 41 pre-operative questionnaires returned - a headline
participation rate of 45.6% (74.7% in England).
Of the 40 post-operative questionnaires sent out by Quality Health after discharge of the patient, 27 have
been returned - a response rate of 67.5% (79.6% in England).
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'
Participation in the survey is not obligatory and we are trying to improve participation rates in order to
affect better data.
2.2 Enhanced Recovery Pathway (ERP)
The ERP is about optimising the patient prior to admission to ensure the best possible outcome and a fast
recovery reducing length of stay. ERP is designed through evidenced based care and focuses on
making sure patients are active participants in their own. 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 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 peri 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
We recently introduced Carbohydrate Loading to our ERP for certain procedures. This has been through
collaborative working with our consultants and the multi-disciplinary team. We are looking at ways to
introduce Joint Schools for our patients by working with teams at other BMI sites within our cluster.
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.
There were 8 unplanned readmissions and 5 returns to theatre out of 5499 cases. This is 0.14% and
0.09% of all admissions respectively. This is well below expected parameters.
3. Patient experience
3.1 Patient satisfaction
BMI Healthcare is committed to providing the highest levels of quality of care to all of our
patients. We continually monitor how we are performing by asking patients to complete a patient
satisfaction questionnaire. Patient satisfaction surveys are administered by an independent third
party. The questionnnaire currently includes the Friends and Family test and we are working at
ways to improve our response rate for this part of the survey.
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMIShirley Oaks
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.
We received 49 complaints and all of these were resolved at stage 1. The most common theme were
queries about charges relating to Private patients. We have now introduced clearer signage and
information leaflets in our Outpatients department that explain the way in which patients are invoiced for
their treatment. They also contain information on the sort of tests that will be undertaken and that they
should ask for a breakdown of costs prior to consenting to tests.
4. CQUINS
BMI Shirley Oaks achieved all CQUINs targets for the year April 2013 to March 2014. CQUINS are quality
improvement initiatives with financial incentives for providers which allow embedding of best practice to
improve patient care delivery.
The indicators were:
VTE – 95% of patients to be assessed on the agreed tool on admission to hospital
Friends & Family Test – participation rate of 15% required
Smoking cessation – 95% of patients who smoke to be offered onward referral for support and advice to
stop smoking.
Nutrition – 100% of patients admitted to hospital would be assessed on their nutritional needs within 24
hours of admission.
Participation in the Safety Thermometer and Infection Prevention Care Bundles.
5. National Clinical Audits
The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) invites providers to take
part in specific audits related to conditions, diseases or procedures. BMI Shirley Oaks is currently
participating in an audit on Gastrointestinal Hemorrhage.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
1.
2.
3.
4.
Complete hospital general refurbishment programme
Develop walk in walk out (WIWO) services
Work with other providers to develop integrated care pathways
Strengthen higher acuity pathways
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for BMI Shirley Oaks
Hospital for the reporting period is not available as it is not pblished until October 2014.
Unit
Reporting Periods
(at least last two reporting
periods)
Oct 11 – Jun 13
National
Average
Highest National
Score
Lowest National
Score
1.0006
1.1822
0.6735
8.2 BMI Shirley Oaks Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
*
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
0.083
0.157
0.014
National
Average
Highest National
Score
Lowest National
Score
-8.738
8.172
-15.918
National
Average
Highest National
Score
Lowest National
Score
21.280
24.684
17.214
National
Average
Highest National
Score
Lowest National
Score
15.99
20.37
12.2
* numbers below 30 cannot be used
(ii) Varicose vein surgery
Unit
*
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
* numbers below 30 cannot be used
(iii) Hip replacement surgery
Unit
*
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
* numbers below 30 cannot be used
(iv) Knee replacement surgery during the reporting period.
Unit
*
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
* numbers below 30 cannot be used
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of BMI Shirley
Oaks Hospital within 28 days of being discharged from a hospital which forms part of the hospital during
the reporting period.
Unit
0
Reporting Periods
(at least last two reporting
periods)
Apr 11 - Mar 12
National
Average
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
BMI Shirley Oaks Hospital considers that this data is as described for the following reasons:
• No paediatric inpatient service at BMI Shirley Oaks
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of BMI Shirley
Oaks Hospital within 28 days of being discharged from a hospital which forms part of the hospital during
the reporting period.
Unit
0.14%
Reporting Periods
(at least last two reporting
periods)
Apr 11 – Mar 12
National
Average
Highest National
Score
Lowest National
Score
10.01
14.51
5.54
BMI Shirley Oaks Hospital is aware that the numbers may be lower as we do not provide an Accident &
Emergency service so patients may present at an NHS Trust. We are working to improve our data
communications with our neighboring NHS hospitals.
8.4 BMI Shirley Oaks Hospital responsiveness to the personal needs of its patients during the reporting
period.
Unit
92.72%
Reporting Periods
(at least last two reporting
periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
BMI Shirley Oaks is pleased with this score but acknowledges further improvement is required to increase
our patient satisfaction.
8.5 The percentage of patients who were admitted to BMI Shirley Oaks 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
Highest National
Score
Lowest National
Score
96
100
79
BMI Shirley Oaks Hospital is pleased with this score and undertakes monthly audits to ensure
compliance. We have a robust admission process that requires VTE risk to be considered at several
points in the pathway.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within BMI Shirley Oaks
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
Highest National
Score
Lowest National
Score
17.3
30.8
0
BMI Shirley Oaks Hospital strives to ensure its patients are cared for in a safe environment and takes
Infection prevention extremely seriously.
8.7 The number and, where available, rate of patient safety incidents reported within BMI Shirley Oaks
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
263
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
44.55
1,810
0
Rate of patient safety incidents reported (Incidents per 100 Admissions)
Unit
4.78
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
7.76
30.95
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
Highest National
Score
Lowest National
Score
0.64
28
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100
Admissions)
Unit
0
Reporting Periods
(at least last two reporting
periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
0.9
2.9
0
8.8 The percentage of staff employed by BMI Shirley Oaks Hospital during the reporting period, who
would recommend BMI Shirley Oaks Hospital as a provider of care to their family or friends.
Unit
%
Reporting Periods
(at least last two reporting
periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
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 BMI Shirley Oaks Hospital as a provider of care to their family or
friends.
Unit
81.55%
Reporting Periods
(at least last two reporting
periods)
Jun 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
BMI Shirley Oaks considers that this data is as described for the following reasons:
• Participation rate too low
• Discharge communication needs improving
BMI Shirley Oaks Hospital is taking the following actions to improve this percentage:
• Strong focus on participation
• Utilising every patient interaction as a means of clarifying discharge information and by providing
information in a number of formats.