BMI The Beardwood 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 Today that work has been superseded by the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
The Beardwood Hospital
BMI The Beardwood Hospital in Blackburn, Lancashire 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 The Beardwood Hospital has 18 single rooms offering the privacy and comfort of en-suite
facilities, satellite TV and telephone. A seven bed day care unit and a high dependency unit,
combined with the latest in technology and support services, enable our consultants to
undertake a wide range of procedures from routine investigations to complex surgery. At The
Beardwood Hospital we have a dedicated Oncology Unit treating a wide variety of cancers
including Breast, Bowel, Prostate, Ovarian, Lung, Lymphoma and Myeloma. We also have a
static CT and MR scanning unit offering state of the art facilities. We were the first private unit
to offer both modalities in Lancashire and Cumbria.
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.
The amount of NHS work we carry out at the Beardwood Hospital has increased steadily over
the last few years. Our current rate of NHS work amounts to 76%. We accept patients from
the Choose and Book network and are also involved in waiting time initiatives, helping to reduce
waiting times in the NHS by taking blocks of patients on spot contracts.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The Beardwood Hospital is registered as a location for the
following regulated services:•
Treatment of disease, disorder and injury
•
•
Surgical procedures
Diagnostic and screening
The CQC carried out an unannounced inspection on the 5th December 2013 and found that The
Beardwood Hospital was meeting all the required standards. The hospital has not been the
subject of any special reviews or investigations. The following five Standards were inspected:
Care and Welfare of people who use the services
Meeting nutritional needs
Safeguarding people who use the services from abuse
Standards of staffing
Complaints
The Beardwood 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. The Director of Nursing and the Governance and Risk
Manager work together closely to ensure the care provided is of the highest standard. The
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.
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 The Beardwood
Hospital.
We have had: • Zero cases of MRSA bacteraemia in the last year (NHS
1.17cases/100,000 bed days).
• MSSA bacteraemia cases 0/100,000 bed days
• E.coli bacteraemia cases 0/100,000 bed days
• Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
• SSI data is also collected and submitted to Public Health England for orthopaedic
surgical procedures. Our rates of infection are;
o Hips 0%
o Knees 0%
,//ƵĚŝƚŽĨWĞƌŝƉŚĞƌĂů/ŶƚƌĂǀĞŶŽƵƐĂŶŶƵůĂ/ŶƐĞƌƚŝŽŶƐ
At The Beardwood Hospital we conduct monthly High Impact Interventions around peripheral
intravenous catheters, central venous catheters, hand hygiene and theatre interventions. The
above two graphs illustrate our results from the peripheral intravenous catheter audits. It was
clear from the result of the first audit of insertion techniques that staff education was needed. A
series of educational workshops were held in all departments to improve staff knowledge of all
the necessary steps required to comply with the High Impact Intervention audit. Following this
we saw a steady increase in compliance with best practice and have reported zero cases of
phlebitis or peripheral catheter related infections.
In the second half of 2013 The Beardwood Hospital appointed a new lead Infection Prevention
and Control Nurse who has brought a wealth of knowledge and experience to the hospital. In
each department we now have an Aseptic Non Touch Technique (ANTT) assessor and,
combined with an e-learning module, they are assessing all clinical staff and their ANTT
capabilities.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
Patient Satisfaction Scores - Cleanliness
ϭϬϬ
ϴϬ
ϲϬ
ϰϬ
ĂƚŚƌŽŽŵůĞĂŶůŝŶĞƐƐ
ZŽŽŵůĞĂŶůŝŶĞƐƐ
ϮϬ
Ϭ
й
s͘'ŽŽĚͬdžĐĞůůĞŶƚ
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. The results below are from
the 2013 PLACE Audit, the 2014 audit has been completed, however, the results are not yet
published.
Following the 2012 Audit, action plans were put in place to improve our scores, the results of the
2013 Audit show how successful these were.
Year
Environment
Food
Privacy & Dignity
2013
92%
83%
92%
2012
75%
72%
86%
2013 PLACE Audit results
1.3 Venous Thrombo-embolism (VTE)
BMI Healthcare, holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including, The Beardwood 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 assess every patient who is admitted to our facility
and the results of our audit on this have shown that we are consistently achieving 100%.
The Beardwood 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. In the year, October 2012 to September 2013 The Beardwood Hospital reported zero
incidence of VTE.
BMI The Beardwood VTE Risk Assessment & Prophylaxis Audit conducted quarterly shows
100% compliance to the corporate Venous Thrombosis Prevention Policy.
The audit consists of;
ƒ Each ward or department admitting patients for day case or in-patient treatments
within a hospital is defined as being a unit, for the purpose of audit.
ƒ
Each individual unit is required to audit 20 consecutive admissions per quarter.
ƒ
The elements being audited are :Risk assessment on admission
Risk assessment within 24 hours of admission
Risk assessment after 7 days, or if patient condition changes
ƒ
The audit is randomised by including a numeric patient identifier only.
ƒ
Consultant and procedure details can be captured which allows the individual units
and hospitals to identify non-compliance.
Audit figures show that from April 1 2012 to March 2013 there were no reported VTE incidents.
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 Beardwood Hospital.
Oxford Hip Score average
April 12 –
Mar 13
Q1
Q2
Health gain (Q2 - Q1 average)
21.071
37.071
16
17.907
39.224
21.317
*Beardwood
England
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'
Oxford Knee Score average
April 12 –
Mar 13
Q1
Q2
Health gain (Q2 - Q1 average)
20.118
39.588
19.471
18.893
34.902
16.01
*Beardwood
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
*Not enough patients to give accurate result
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
BMI The Beardwood Hospital has been represented at the BMI Healthcare ERP conference.
Following this conference a local ERP working party has been formulated to fully implement
best practice model pathways. Areas that are to be focused upon are;
•
Consultant education
•
Pre operative carbohydrate loading
•
Review of medication used in Spinal Anesthetics’
•
Pre-operative warming of patients
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.
During the reporting year The Beardwood Hospital re-admitted 4 patients within 31 days of
surgery and had 6 patients who had an unplanned return to theatre. All of these variances are
formally reported and discussed as the local Clinical Governance Meetings and Medical
Advisory Committee meetings to ensure that lessons learnt and changes to practice are
reviewed and appropriate changes made.
hŶƉůĂŶŶĞĚZĞĂĚŵŝƐƐŝŽŶǁŝƚŚŝŶϯϭĚĂLJƐ;ZĂƚĞ
ƉĞƌϭϬϬŝƐĐŚĂƌŐĞƐͿ
Ϭ͘ϯϱϬ
Ϭ͘ϯϬϳϲ
Ϭ͘ϯϬϬ
Ϭ͘ϮϱϭϬ
ϮϬϬϵ
Ϭ͘ϮϱϬ
Ϭ͘ϮϬϬ
ϮϬϭϬ
Ϭ͘ϭϴϭϯ
ϮϬϭϭ
Ϭ͘ϭϰϲϮ
Ϭ͘ϭϱϬ
ϮϬϭϮ
Ϭ͘ϭϬϬ
Ϭ͘ϬϲϬϳ
Ϭ͘ϬϲϬϲ
Ϭ͘ϬϱϬ
ϮϬϭϯ
ϮϬϭϰ
ϮϬϭϰ
ϮϬϭϯ
ϮϬϭϮ
ϮϬϭϭ
ϮϬϭϬ
ϮϬϬϵ
Ϭ͘ϬϬϬ
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 and The Beardwood Hospital scored 98.8% Very Good or Excellent for Overall Rating of
Quality of Care.
ϵϵ
ϵϴ
ϵϳ
йƐĐŽƌŝŶŐsĞƌLJ
'ŽŽĚŽƌdžĐĞůůĞŶƚ
ĚŵŝƐƐŝŽŶ
ϵϲ
EƵƌƐŝŶŐ
ϵϱ
ĐĐŽŵŵŽĚĂƚŝŽŶ
ϵϰ
ĂƚĞƌŝŶŐ
ϵϯ
KǀĞƌĂůů
ϵϮ
ϵϭ
ĚŵŝƐƐŝŽŶ EƵƌƐŝŶŐ
ĐĐŽŵ
ĂƚĞƌŝŶŐ
KǀĞƌĂůů
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
The Beardwood 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.
At The Beardwood Hospital we continually strive to improve our services and listen to the
feedback we receive from our customers. This has resulted in a fall in the number of complaints
we have received over the past 12 months.
4. CQUINS
In 2009 the NHS Commissioning Board introduced the Commissioning for Quality and
Innovation (CQUIN) framework. This was introduced to ensure improvements in the
quality of services and better outcomes for patients.
During 2013 – 2014 BMI The Beardwood Hospital complied with the National CQUINS
program as part of the contractual arrangements with the local Clinical Commissioning
Groups. Data was collected and submitted for VTE Risk Assessment, the Patient Safety
Thermometer and the Friends and Family Test. The monthly audit of VTE assessment
showed extremely high compliance at The Beardwood Hospital. The Patient Safety
Thermometer which looks at the number of falls, and Health care associated infection
relating to urinary catheters similarly showed excellent results.
In addition to the National CQUIN’s there were also locally agreed CQUIN’s which for
2013-2014 included
1. Care Bundle Audits of Indwelling Urinary catheters. This measure looked at the
appropriate use of catheters and therefore reducing the likelihood of patients
having a Health Care Associated Infection.
Ϯ͘ Care Bundle Audits of Peripheral Vascular Access Devices. This measure was
similarly looking at the appropriate use and length of time peripheral devices
were used. By keeping the time the devices are in situ to a minimum this
reduces the likelihood of an infection.
ϯ͘ Post Discharge follow-up telephone calls. This measure required us to call
patients 24-48hrs after their discharge from hospital to ensure they were well
and were not experiencing any problems. If patients were found to be having
problems a member of the clinical team would speak with them and try and
resolve any issues.
CQUIN measure
TARGET
Apr13 – Mar14
Friends & Family
20%
20.3%
Safety
Thermometer
Yes
Yes
VTE Risk
Assessment
100%
100%
Post Discharge
Follow up calls
Number of PVD
infections
75%
82.25%
0
0
100%
100%
Management plan
in place for
indwelling
urinary catheters
5. National Clinical Audits
The Beardwood Hospital was only eligible to participate in National Joint Registry audit and all
joint replacements are submitted to this.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
•
•
•
•
Cancer Pathway extension to offer current established clinical services to those patients
who require it in partnership with local Trust MDT
Pre-operative Physiotherapy inclusion to mitigate against patient referral back to GP
Extending ophthalmology services beyond cataract surgery
Pain management pathway including pre-post intervention physiotherapy and
psychological assessment.
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for BMI
The Beardwood Hospital for the reporting period is due to be published in October 2014
and is therefore unavailable for this report..
Unit
N/A
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 The BMI Beardwood Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
Reporting Periods
National
(at least last two
Average
reporting periods)
*0.104
Apr 12 – Mar 13
0.083
*Not enough patients to give accurate result.
Highest National
Score
Lowest National
Score
0.157
0.014
Highest National
Score
Lowest National
Score
(ii) Varicose vein surgery - Unable to report as no data.
Unit
N/A
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
(iii) Hip replacement surgery
Unit
Reporting Periods
(at least last two
reporting periods)
*16
Apr 12 – Mar 13
National
Average
-8.738
8.172
-15.918
National
Average
Highest National
Score
Lowest National
Score
21.280
24.684
17.214
*Not enough patients to give accurate result.
(iv) Knee replacement surgery during the reporting period.
Unit
Reporting Periods
National
(at least last two
Average
reporting periods)
*19.471
Apr 12 – Mar 13
15.99
*Not enough patients to give accurate result.
Highest National
Score
Lowest National
Score
20.37
12.2
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
BMI Beardwood Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
Reporting Periods
National
Highest National
(at least last two
Average
Score
reporting periods)
N/A
Apr 11 - Mar 12
11.45
14.35
No inpatient paediatric services provided at BMI Beardwood Hospital
Lowest National
Score
7.96
8.3. (ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the BMI Beardwood within 28 days of being discharged from a hospital which forms part of the
hospital during the reporting period.
Unit
0.060%
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
8.4 The BMI Beardwood Hospital responsiveness to the personal needs of its patients during
the reporting period.
Unit
92.22%
Reporting Periods
(at least last two
reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
8.5 The percentage of patients who were admitted to BMI Beardwood 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
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the BMI
Beardwood 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
8.7 The number and, where available, rate of patient safety incidents reported within the 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
200
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
National
Average
Highest National
Score
Lowest National
Score
7.76
30.95
1.68
Rate of patient safety incidents reported
Unit
3.03
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
Number of patient safety incidents that resulted in severe harm or death
Unit
1
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
Unit
0.015%
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
0.9
2.9
0.0
8.8 The percentage of staff employed by the BMI Beardwood during the reporting period, who
would recommend the BMI Beardwood as a provider of care to their family or friends.
Unit
96%
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 the BMI Beardwood Hospital as a provider of care
to their family or friends.
Unit
82.27%
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