BMI St Edmunds 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 Today that work has been superseded by the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.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
The information available in these quality accounts has been reviewed by the Clinical
Governance Board and I declare that as far as I am aware the information contained in these
reports is accurate. I thank all the staff whose energy and devotion to improvement is
represented here and, more importantly, in the experiences of every patient who steps across
our threshold.
Stephen Collier
Chief Executive Officer
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
Hospital Information
BMI St Edmunds Hospital has 31 beds with all rooms offering the privacy and comfort of ensuite facilities, satellite TV, wi-fi access and telephone. 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.
The fire system upgrade has been completed. The uninterrupted power supply system has been
replaced.
NHS work currently accounts for 38% of our overall work. We currently offer orthopaedics,
hernia repairs, cataract surgery, gynaecology, limited colo-rectal and urology services on
Choose and Book. We are also continuing our AQP contract for West Suffolk Adult Carpel
Tunnel service.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI St Edmunds Hospital is registered as a location for the
following regulated services:• Treatment of disease, disorder and injury
• Surgical procedures
• Diagnostic and screening
We are in the process of registering for Family Planning services.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
The CQC carried out an unannounced inspection on 17th December and found one standard not
met which was in relation to quality assurance in assessing and monitoring the quality of service
provision covering infection prevention and control, equipment and maintenance.
Care and welfare of people who use the services
Cleanliness and infection control
Safety, availability and suitability of equipment
Records
Assessing and monitoring the quality of service provision
[
Actions taken to correct the findings against this standard have included:
• Uninterrupted Power Supply has now been replaced so emergency back-up for theatre
power is now in place to cover until generator kicks in. This will ensure that the
continuous monitoring of patients in theatre and that the laparoscopic stack is
operational throughout any power interruption. As an additional measure an alarm has
been installed in theatres to alert staff if the UPS is non-operational. Completed April
2014.
• Equipment management has now been streamlined onto one central register available
to all Heads of Department and Electrical and Biomedical Engineer (EBME) Champion.
All service records, maintenance contracts and manuals for each piece of bio-medical
equipment are now maintained in each relevant department and are accessible to staff.
Additionally all EBME equipment has been tagged with last and next service date and
contact number of company responsible for servicing.
• The Executive Director is now meeting with site engineer fortnightly to improve
communication to site about any risks/safety issues identified in relation to
responsibility of site engineer. This is an agenda driven meeting. In addition, the
Regional Engineer now has access to the site Risk Register to allow equipment issues
to be reported and tracked on site, with appropriate feedback then provided at all
relevant meetings. This will ensure that communication up and down the business is
sustained across this the site.
• The hospital’s Director of Infection Prevention and Control role has been taken over by
the Director of Clinical Services. The Infection Prevention and Control (IPC) meetings
have been re-structured so the agenda pulls together all areas identified into a standard
agenda.
• IPC Environmental audits have been undertaken in the ward, theatres and outpatient
departments using the Infection Prevention Society’s National Quality Improvement
tools and action plans are in progress against findings.
• Minutes of IPC meetings are being issued within 10 working days of the meeting.
• Out of date corporate policies escalated to Corporate and are in process of review. The
Corporate Lead for Infection Prevention and control is currently reviewing these policies
and we have been informed this review will be complete by the end of June 2014.
• The Corporate Group IPC annual programme already exists and a copy of the
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
programme is held on site as well as being accessible on collaboration site for all staff.
• Housekeeping audits are now being made using a newly adapted audit tool and trends
are being discussed at IPC meetings as well as with relevant staff. These are being
conducted by the housekeeping lead and housekeeper or Head of IPC.
• Recording form of water temperatures did not denote which taps have thermostatic
valves in situ for which a lower water temperature would be expected. The senior
engineer has devised a form to capture this information which will be fed into the site
Water Safety Management meeting on a quarterly basis to update the IPC team on
site. There is a column on the form for actions taken to address any issues identified
and what the outcome of the action has been.
BMI St Edmunds 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 analyses 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 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.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
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 St Edmunds 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 St
Edmunds Hospital.
We have had: • Zero cases of MRSA bacteraemia in the last year (NHS
1.17cases/100,000 bed days).
• Zero cases of MSSA bacteraemia cases /100,000 bed days
• Zero cases of E.coli bacteraemia cases/ 100,000 bed days
• Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
• SSI data is also collected and submitted to Public Health England for orthopaedic
surgical procedures. Our rates of infection are;
o 1 Hip infection (125 procedures under NHS = 0.8%)
o 0 Knee infection (89 procedures under NHS)
An external company undertook a sharps audit which did not identify any issues. The infection
control Co-coordinator attends infection control meetings at the local NHS Trust as well as
facilitating regular meetings on site.
High Impact Intervention Care Bundles audits have been rolled out for intravenous peripheral
catheters and urinary catheterization and hand hygiene.
Prevention focused activities have been on hand hygiene and aseptic non touch technique and
documentation in relation to care bundles for intravenous peripheral catheters and urinary
catheters.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
Patient satisfaction of room cleanliness
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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.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
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. Areas identified at time of
audit included grounds maintenance with regard to signing the drop-off point and storage of delivery
pallets, attention to housekeeping on radiator covers and sink taps, flooring in toilet, and food around
courses being served at same time.
Actions to improve this have been taken in all areas with improved signage, tidying external area,
increasing the frequency of cleaning of the radiators in the reception and outpatient area, new
flooring planned for toilet in outpatient and review of food service.
The latest results are not yet available on website.
Last year’s results for
2013:
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, St Edmunds 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.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
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 inpatient who is admitted to our
facility and the results of our audit on this has shown We intend to maintain our 100%
compliance with continued monthly auditing, maintaining a VTE Champion on the ward staff
and spot checks.
St Edmunds 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. .
There have been no reported incidents of DVT or PE in the year April 2013 to March 2014 at St
Edmunds Hospital.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
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 BMI St Edmunds Hospital.
Oxford Hip Score average
2013
BMI St
Edmunds
Q1
Q2
Health gain (Q2 - Q1 average)
19.897
42.287
22.391
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.'
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
Oxford Knee Score average
2013
BMI St
Edmunds
Q1
Q2
Health gain (Q2 - Q1 average)
20.75
34.938
14.188
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)
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. Pre-Admission Education sessions
c. Optimizing the patient prior to admission – i.e Carbohydrate loading, 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 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
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
At St Edmunds Hospital we have introduced carbohydrate loading and more robust screening
processes into our pre-assessment clinics. Pre-assessment has expanded to include telephone
pre-assessment for those patients not requiring face to face assessment post screening of
medical health questionnaire. We are now pre-assessing the majority of patients planned for
general anaesthesia and additionally are telephone pre-assessing many patients or screening in
outpatients many of the patients undergoing procedures under local anaesthesia.
In 2014-15 we are planning the introduction of group education classes for joint surgery patients
and to bring the physiotherapy service in house at St Edmunds Hospital.
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.
In 2013 -14 St Edmunds Hospital has had 4 unplanned re-admissions.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
In the period April 2013 to March 2014 St Edmunds Hospital has had no unplanned returns to
theatre.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
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.
During the year from 1st July to 31st December St Edmunds Hospital took part in a postal card
patient questionnaire survey for the Friends and family accumulator question.
Although this
undoubtedly improved both patient questionnaire feedback and friends and family participation it
was unaceptable to site as there was a three month time lapse in getting results which meant
the Hospital were unable to investigate or act quickly to changes in performance.
From 1st January the usual Quality Helath questionnaires were resumed. However it meant we
had a month with very low data results and patients particpating in the postal survey were not
followed through and it takes a while for patients to respond with their questionnaires.
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This year has seen a focus on pain control and discharge planning. These areas were also
highlighted in the patient focus group. A pain team has been establisehd in the hospital and we
have produced an information sheet of contacts for organisations which can assist to support
patients on discharge. It is hoped this will improve the overall discharge process. Scores for
planning of deparrture and instructions for aftercare have improved during the year.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI Sƚ
ĚŵƵŶĚƐHospital 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 all BMI St Edmunds hospital received 19 complaints 2013-2014 (0.678 per 100 admissions).
11 of these were clinical complaints.
Admission process
Waiting time post admission for surgery
Waiting time in outpatients for appointment
Staff attitude
Unsuccessful procedure
4
1
2
2
2
Full responses have been made to patients and improvement actions undertaken where
identified. Admission processes are being reviewed to ensure information goes out in good time
for patient bookings.
Transparency around fee prices appears to have worked well and there have been no billing
complaints in relation to hidden costs or fees for this year.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
4. CQUINS
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BMI St. Edmunds Hospital - CQUIN Quarter 4 Report (Jan - Mar 2014)
Friends and Family Test (N1)
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Requirement and Target
1.2
FFT Response Rate - 20% by Q4 (current response rate)
Yes
1.3
FFT Implementation of question in staff survey by Q4
Yes
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Requires monthly surveying all appropriate patients to collect
data on pressure ulcers, falls, UTI in patients with catheters and
VTE. A completed Safety Thermometer survey for all relevant
patients must be included for each month in the relevant
quarter’s submission to trigger payment.
Safety Thermometer survey data for all appropriate patients, in
all appropriate settings for relevant measures submitted (to
NHS Information Centre by BMI IMU)?
Yes
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Target
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1.4
Pt satisfaction score
Score
NHS Safety Thermometer (N2)
Description
of Indicator
VTE Risk Assessment (N3.1)
Description
of Indicator
Performance
% of adult inpatients who have had a VTE risk
assessment on admission to hospital using the
clinical criteria of the national tool
Percentage of adult inpatient admissions
reported as having had a VTE risk assessment
on admission to hospital using the clinical
criteria of the national tool (Numerator /
Denominator x 100)
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
VTE Root Cause Analysis (N3.2)
Description
% of root cause analyses carried out on cases
of Indicator
of hospital associated thrombosis
Percentage of cases of hospital associated
Performance thrombosis where a root cause analysis has
been carried out
Catheter Audit (L4.1)
Description
of Indicator
To increase best practice use of catheters
Number of Patient records audited capturing
Performance surgical care bundles per month
Catheter Audit (L4.2)
Description
of Indicator
To increase best practice use of catheters
Percentage of Patient audited capturing
Performance surgical care bundles per month
Post-Surgical Follow Up Audit (L5.1)
Description
To record and increase post-surgical telephone
of Indicator
follow-ups.
Number of Patient records audited capturing
Performance Post-Surgical Remote Follow Ups completed
per month
Post-Surgical Follow Up Audit (L5.2)
Description
To record and increase post-surgical telephone
of Indicator
follow-ups.
Percentage of Patient audited capturing postPerformance surgical telephone follow ups
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Target
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Target
Improvement
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Target
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Target
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Target
Lifestyle Intervention Audit (L6.1)
Description
of Indicator
Performance
Lifestyle Interventions: Patients with BMI >30
offered advice and signposted to appropriate
services
Number of Patient records audited with
completed risk assessment for weight
associated health issues per month.
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
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Lifestyle InterventionAudit (L6.2)
Description
of Indicator
Performance
Lifestyle Interventions: Patients with BMI >30
offered advice and signposted to appropriate
services
Percentage of Patient audited capturing BMI
>30 with lifestyle advice given
Both the surgical follow up phone calls and lifestyle intervention on giving health education
information on patients with a BMI of >30 were not achieved. For both of these the targets were
100% capture which meant a failure to achieve on one patient saw a failure to achieve target.
Out of the 151 patients audited this equated to 3 missed follow up calls. The ward has increased
the amount of emphasis put onto this for the year ahead to ensure 100% capture rate.
The health education for patients with a BMI >30 has been integrated into the pre-assessment
clinic for patients face to face but has been frequently overlooked for patients not attending for
face to face pre-assessment due to the volume of paperwork at time of admission. More focus is
being directed at this for the year ahead.
5. National Clinical Audits
St Edmunds 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 223 onwards in the latest
NJR report.
The BMI ST Edmunds hospital demonstrates data that based on the type of patients seen at
this hospital are 90 day mortality dates are well within the national averages for these types of
surgery.
The 2013 Annual Report states a 98% consent rate for year 2012 up on the previous year of
97%.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
For the year 2014 -15 priorities for service development will be focused on:
1) Bringing the physiotherapy service in-house and expanding the ability to treat
outpatients.
2) Planned rolling refurbishment program to replace ward patient room carpets with hard
flooring to improve infection control compliance.
3) Replacement of some of the ophthalmic diagnostic equipment and biometry.
4) Consider the capacity to take on 2 week referrals (not urgent cancer care) within the
choose and book clinics.
8. Mandatory Quality Indicators
8.1 There have been no reported deaths at the BMI St Edmunds hospital for year 2013-14.
8.2 The BMI St Edmunds Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
average
Reporting Periods
(at least last two
National
Average
Highest National
Score
Lowest National
Score
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
<30 so
unable to
score
reporting periods)
April 12 – Mar 13
0.083
0.157
0.014
National
Average
Highest National
Score
Lowest National
Score
21.280
24.684
17.214
Not enough cases were undertaken to score on the PROMs
(ii) Hip replacement surgery
Unit
Average
23.06
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
The BMI St Edmunds Hospital considers that this data is as described for the following reasons:
• Active enhanced recovery program in place
• Hip pathways in use
The BMI St Edmunds Hospital intends to take the following actions to improve this score and so
the qualities of its services, by reviewing analgesic régime patients are discharged home on and
by commencing group physiotherapy sessions.
(iii) Knee replacement surgery during the reporting period.
Unit
Average
14.422
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
15.99
20.37
12.2
The BMI St Edmunds Hospital considers that this data is as described for the following reasons:
• Active enhanced recovery program in place
• Knee pathways in use
The BMI St Edmunds Hospital intends to take the following actions to improve this score and so
the qualities of its services, by reviewing analgesic régime patients are discharged home on and
by commencing group physiotherapy sessions.
8.3 The BMI St Edmunds Hospital responsiveness to the personal needs of its patients during
the reporting period.
Unit
Average
Reporting Periods
(at least last two
reporting periods)
National
Average
Highest National
Score
Lowest National
Score
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
82.18%
April 2013 – Mar 2014
68.1
84.4
57.4
The BMI St Edmunds Hospital needs to maintain this level of care and commitment to patients
and ensure the number of questionnaire returns remains high.
8.4 The percentage of inpatients who were admitted to BMI St Edmunds 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
The BMI St Edmunds Hospital considers that this data is as described for the following reasons:
• The VTE risk assessment has been incorporated into the medication chart which has
clearly reminded staff to complete.
The BMI St Edmunds Hospital must maintain this level of compliance going forward and will
undertake regular audits to ensure this pathway is followed.
8.5 The number and, where available, rate of patient safety incidents reported within the BMI St
Edmunds 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
87
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
44.55
1810
0
National
Average
Highest National
Score
Lowest National
Score
Rate of patient safety incidents reported
Unit
Reporting Periods
(at least last two
reporting periods)
BMI St Edmunds Hospital Quality Accounts
April 2013 to March 2014
3.1072
Apr 13 –Mar 14
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 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
0.64
28
0
Percentage of patient safety incidents that resulted in severe harm or death
Unit
0.00%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Mar 14
National
Average
Highest National
Score
Lowest National
Score
0.9
2.9
0.00
The BMI St Edmunds Hospital considers that this data is as described for the following reasons:
• The Hospital has a robust reporting process where clinical incidents are reported
regardless of whether there was an adverse outcome.
The BMI St Edmunds Hospital intends to continue to monitor this adverse clinical occurrence
rate through its bi-monthly clinical governance meetings ensuring actions are taken to reduce
the likelihood of future incidents occurring through root cause analysis and preventative actions.