15/17 Fairfax Drive
Westcliff on Sea
Essex
SS0 9AG
Quality Accounts
2013/14
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 Today that work has been superseded by the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 Southend Hospital is a remarkable, state of the art building offering a day care patient
service. The hospital is renowned for its ophthalmology and cosmetic surgery specialisms, also
offering orthopedic, general day surgery, gynaecology.
BMI Southend Hospital is easily located at the junction of Prittlewell Chase and Fairfax Drive,
near to Priory Park. Just 400 yards from Southend NHS Foundation Trust Hospital and within
easy access to all forms of public transport. The facilities include:
Two fully modern equipped theatres, capable of general anaesthesia
Two stage recovery bays (5 beds)
Patient preparation & changing facilities
Cosmetic laser room
Eye laser facility
An outpatient suite with 7 consulting rooms and treatment areas
On site free parking
Services provided by BMI Southend Hospital are as follows:
Outpatient Services for private consultations with consultants. Specialties offered are:
• Ophthalmology
• Breast Surgery
• Cosmetic Surgery
• Dermatology
• ENT surgery
• General surgery
• Gynaecology
• Histopathology
• Podiatry
• Laparoscopic surgery
•
•
•
•
Orthopaedic surgery
Pathology
Plastic and reconstructive surgery
Vascular surgery
Operating facilities 2
Theatre suites equipped with facilities for general/sedation/local anaesthetics. Specialities
offered are:
• Ophthalmic Surgery – including cataract, vitrectomy, glaucoma, lens replacement
and laser eye surgery
• Plastic/Cosmetic Surgery – including Breast Surgery
• General Surgery - including Hernia and Vascular Surgery
• Orthopedic surgery
• Gynecology
• Ear Nose & Throat
• Podiatry
Statistics for NHS work at BMI Southend are shown below:
Outpatients
Oct 12 to Sept 13
Oct 13 to April 14
% of NHS to
Total Activity
Total Outpatient Activity
2440
NHS Activity
1695
Total Outpatient Activity
1779
NHS Activity
1333
Total Theatre Activity
1407
NHS Activity
1011
Total Theatre Activity
1134
69%
75%
Theatre
Oct 12 to Sept 13
Oct 13 to April 14
NHS Activity
880
72%
78%
NHS Activity is predominately Ophthalmic with Plastic, General Surgery.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Southend Hospital is registered as a location for the
following regulated services:•
•
•
•
Acute hospital (day surgery only)
Prescribed techniques or prescribed technology: establishments using Class 3B or Class
4 lasers (PT(L))
Diagnostic and screening procedures
Fertility Services
•
Services may only be provided to persons aged 18 years and over
The CQC carried out an unannounced inspection on December 2013 and found state
compliance as detailed below:
Respecting and involving people who use services
Standard Met
Consent to care and treatment
Standard Met
Care and welfare of people who us services
Standard Met
Safeguarding people who use services from abuse
Standard Met
Cleanliness and infection control
Standard Met
Support workers
Standard Met
Assessing and monitoring the quality of service provision
Standard Met
Southend Hospital has a local framework through which clinical effectiveness, clinical incidents
and clinical quality is monitored and analysed. Where appropriate, action is taken to
continuously improve the quality of care. This is through the work of a multidisciplinary group
and the Medical Advisory Committee.
Regional Clinical Quality Assurance Groups monitor and analyze trends and ensure that the
quality improvements are operationalized. There has been development of
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 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 link nurse in Southend Hospital
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 Southend
Hospital
We have had: • Zero cases of MRSA bacteremia in the last year (NHS
1.17cases/100,000 bed days).
• Zero cases of hospital apportioned Clostridium difficile in
the last 12 months.
Infection control audits are carried out on a quarterly basis with monthly surveillance reported at
a central level. All identified HAIs are fully investigated for any trends – of which none have
been identified at BMI Southend Hospital. Our infection rates remain well below average with no
major incidences. These outcomes are as a direct result of the stringent pre-assessment and
high standard of clinical care delivered during and after surgery.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
As a day case hospital without inpatient bedrooms, the patient survey does not cover patient
rooms but below is the patient survey results for the outpatient facilities, this covers cleanliness
and general facilities offered (e.g. beverages, newspapers etc).
1.2 Patient Led Assessment of the Care Environment (PLACE)
We believe a patient should be cared for with compassion and dignity in a clean, safe
environment. Where standards fall short, they should be able to draw it to the attention of
managers and hold the service to account. PLACE assessments will provide motivation for
improvement by providing a clear message, directly from patients, about how the environment
or services might be enhanced.
In 2013 we introduced PLACE, 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. As BMI Southend
Hospital is a day case facility with no inpatient beds we are not required to carry out a PLACE
audit, we do however ensure through our patient surveys that the patient experience is of the
highest quality.
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 Southend 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 every patient and the results of 100%.
We continue to work with our consultants and referrers in order to ensure that we have as much
data as possible.
BMI Southend 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.
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 programed.
Latest results can be found by going on the online SOLAR system provided to you by Quality
Health
BMI Southend Hospital does not carry out hip and knee surgery but inguinal hernia repair and
varicose vein surgery when carried out, patients who consented to participate did complete
questionnaires.
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 Southend hospital
Oxford Hip Score average
2013
Q1
Q2
BMI
Southend
Hospital
Health gain (Q2 - Q1 average)
These procedures are not carried out at
BMI Southend Hospital
0.339
0.767
0.429
England
Oxford Knee Score average
2013/2014
Q1
Q2
BMI
Southend
Hospital
Health gain (Q2 - Q1 average)
These procedures are not carried out at
BMI Southend Hospital
0.387
0.709
0.321
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
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, 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
All clinical staff at BMI Southend Hospital have attended ERP training to ensure that patients
are treated with the ERP principles. During our recent CQC inspection we were judged to
provide excellent patient satisfaction rates.
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.
Nil unplanned readmissions attained at BMI Southend Hospital
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.
BMI Southend Hospital consistently scores highly in all categories of the patient satisfaction
survey. This however does not make us complacent and we continually review our processes
and procedures to ensure the best possible delivery of care is maintained.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Southend 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.
In 2013 BMI Southend Hospital had zero complaints.
4. CQUINS
BMI Southend Hospital collects all required information on CQUINS and this is submitted
centrally on a quarterly basis.
5. National Clinical Audits
BMI Southend Hospital is not eligible for the National Joint Register.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
Based on what our patients tell us and all of our monitoring activity the Board will be supporting
our focus on the following areas:•
•
•
•
Ongoing engagement with NHS commissioners to enhance patient choice and
service delivery to NHS patients will be measured by agreed quality indicators
Further develop and enhance availability of performance and quality indicators for
patients, consultants, referrers and commissioners.
Improvements in the management of complaints and responses to patients with roll
out of a corporate tool kit.
To extend the range and choice of some of our services to provide the best possible
care to our patients, enabling them to make informed choices with their consultant for
their care and treatment.
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Southend Hospital) for the reporting period.
Unit
Value
and
Banding
Reporting Periods
(at least last two
reporting periods)
N/A
National
Average
Highest National
Score
Lowest National
Score
8.2 The Southend Hospital patient reported outcome measures scores for:
(i) Groin hernia surgery
Unit
Number
Reporting Periods
(at least last two
reporting periods)
N/A
National
Average
Highest National
Score
Lowest National
Score
National
Average
Highest National
Score
Lowest National
Score
National
Average
Highest National
Score
Lowest National
Score
(ii) Varicose vein surgery
Unit
Number
Reporting Periods
(at least last two
reporting periods)
N/A
(iii) Hip replacement surgery
Unit
Number
Reporting Periods
(at least last two
reporting periods)
NA
Southend Hospital does not carry out this procedure
(iv) Knee replacement surgery during the reporting period.
Unit
Number
Reporting Periods
(at least last two
reporting periods)
NA
National
Average
Highest National
Score
Lowest National
Score
Southend Hospital does not carry out this procedure
8.3 (i) the percentage of patients aged 0-14 readmitted to a hospital which forms part of the
Southend Hospital within 28 days of being discharged from a hospital which forms part of the
hospital during the reporting period.
Unit
%
Reporting Periods
(at least last two
reporting periods)
NA
National
Average
Southend Hospital does not take pediatric cases.
Highest National
Score
Lowest National
Score
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the Southend Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
%
Reporting Periods
(at least last two
reporting periods)
0%
National
Average
Highest National
Score
Lowest National
Score
8.4 The Southend Private Hospital responsiveness to the personal needs of its patients during
the reporting period.
Unit
%
Reporting Periods
(at least last two
reporting periods)
N/A
National
Average
Highest National
Score
Lowest National
Score
8.5 The percentage of patients who were admitted to Southend Private Hospital and who were
risk assessed for venous thromboembolism during the reporting period.
Unit
%
Reporting Periods
(at least last two
reporting periods)
N/A
National
Average
Highest National
Score
Lowest National
Score
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Southend
Hospital amongst patients aged 2 or over during the reporting period.
Unit
Rate
Reporting Periods
(at least last two
reporting periods)
National
Average
Highest National
Score
Lowest National
Score
0
BMI Southend Hospital considers that this data is as described for the following reasons
Infection control audits are carried out on a quarterly basis with monthly surveillance reported at
a central level. All identified HAIs are fully investigated for any trends – of which none have
been identified at BMI Southend Private Hospital. Our infection rates remain well below average
with no major incidences. These outcomes are as a direct result of the stringent preassessment and high standard of clinical care delivered during and after surgery.
BMI Southend Hospital (intends to take/has taken) the following actions to improve this
(percentage/proportion/score/rate/number), and so the quality of its services, by (insert
description of actions).
8.7 The number and, where available, rate of patient safety incidents reported within the BMI
Southend 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
Number
Reporting Periods
(at least last two
reporting periods)
N/A
National
Average
Highest National
Score
Lowest National
Score
National
Average
Highest National
Score
Lowest National
Score
Rate of patient safety incidents reported
Unit
Rate
Reporting Periods
(at least last two
reporting periods)
N/A
Number of patient safety incidents that resulted in severe harm or death
Unit
Number
Reporting Periods
(at least last two
reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Nil
Percentage of patient safety incidents that resulted in severe harm or death
Unit
%
Reporting Periods
(at least last two
reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Nil
8.8 The percentage of staff employed by BMI Southend hospital during the reporting period,
who would recommend BMI Southend Hospital as a provider of care to their family or friends.
Unit
%
Reporting Periods
(at least last two
reporting periods)
86%
National
Average
Highest National
Score
Lowest National
Score
BMI Southend Hospital considers that this data is as described for the following reasons,
statistics taken from recent BMI Staff Survey.
9. Non-Mandatory Quality Indicators
9.1 The percentage of patients who received care as inpatients or discharged from A &E during
the reporting period, who would recommend the BMI Southend Hospital as a provider of care to
their family or friends.
Unit
%
Reporting Periods
(at least last two
reporting periods)
N/A
National
Average
Highest National
Score
Lowest National
Score
