BMI the Beaumont 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 Today that work has been superseded by the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
ϭͮW Ă Ő Ğ represented here and, more importantly, in the experiences of every patient who steps across
our threshold.
Stephen Collier
Chief Executive Officer
ϮͮW Ă Ő Ğ BMI The Beaumont Hospital
BMI The Beaumont Hospital in Bolton, 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 Beaumont Hospital has 20 rooms all offering the privacy and comfort of en-suite
facilities, satellite TV and telephone. The hospital has three operating suites, including one
specifically designed for orthopaedic surgery.
These facilities combined with the latest in technology and on-site support services; enable our
consultants to undertake a wide range of procedures from routine investigations to complex
surgery.
This specialist expertise is supported by caring and professional medical staff, with dedicated
nursing teams and Resident Medical Officers on duty 24 hours a day, providing care within a
friendly and comfortable environment.
In response to patient feedback during the last 12 months there have been a number of facility
developments including the creation of a dedicated waiting room for outpatients attending for
minor surgery as “walk-in, walk-out” patients. This has ensured that there is a quiet space
available away from the general waiting areas for patients attending for minor operations. In
addition there is a concierge service for patients being admitted to the ward so reducing the
ϯͮW Ă Ő Ğ amount of time that patients are waiting in reception to be admitted to the ward. This has
resulted in an increase in patient satisfaction and patients being calmer in readiness for surgery.
BMI the Beaumont Hospital offers surgical services for adult patients as part of the Choose &
Book offering in addition to the private and self-pay market. Medical services are offered to
private patients. Over the 12 month period being reported this has accounted for 72% of activity
with the remaining percentage being made up of private and self-pay cases.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI the Beaumont 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 5th June 2013 and found that the hospital
was fully compliant on the following standards that were inspected on the day:
Care and welfare of people using the services
Management of medicines
Safety, availability and suitability of equipment
Assessing and monitoring the quality of service provision
Complaints
The CQC report is available on the website however a summary from the CQC report is
documented below:
During the visit we sampled four patient's care files. We found care had been delivered as
documented, within each care pathway, for the particular speciality and treatment.
We observed staff speaking with patients in a professional but friendly manner. We saw that
they knocked on doors and waited before entering patient's rooms. When we spoke with two
patients we were told: "The staff has been great so far, everything has been explained and they
have been extremely pleasant" and "The Nurses here have been like a family, nothing has been
too much trouble, I can't praise them enough".
We found there were appropriate systems in place to ensure the safe management of
medicines. The hospital had a pharmacy on site and employed two pharmacists. There were
current corporate medicines policies and procedures in place for staff guidance.
The Beaumont had appropriate arrangements in place to monitor the quality of the service
provided. Regular audits had been undertaken and these included health and safety, hand
ϰͮW Ă Ő Ğ hygiene and infection control. Action plans had been implemented and updates on how these
were completed were discussed at head of department meetings and individual ward and
department meetings.
We found information on how to make a complaint available for patients and visitors throughout
the hospital via the "Please tell us" leaflets. We spoke with patients who said staff had informed
them about how to raise issues and about the leaflets.
BMI The Beaumont 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 analyse trends and ensure that the
quality improvements are operationalised. 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 Director of Infection Prevention and
Control and Group Head of Infection Prevention and Control, in
liaison with the Infection Prevention and Control Lead at The
Beaumont Hospital. A significant focus has been centered on
this area following the appointment of the IPC Lead and a
detailed report follows:
ϱͮW Ă Ő Ğ We have had: • Zero cases of MRSA bacteraemia in the last year (NHS 1.17cases/100,000 bed days).
• 0 MSSA bacteraemia cases /100,000 bed days
• 0 E.coli bacteraemia cases/ 100,000 bed days
• 0 of hospital apportioned Clostridium difficile in the last 12 months.
PHE SSISS – Hip & Knee Replacements
In October 2013 BMI Beaumont joined the Public Health England (PHE) Surgical Site Infection
Surveillance System (data was previously collected at an organizational level), actively
collecting data on all patients receiving hip and knee replacements and submitting rates of
infection to the PHE. The first formal report was published in March 2014 which is available for
all to view on-line; it depicts the rate of infection for both The Beaumont and the NHS as a
whole. In summary:
Surgery
Quarter
Total
No
No
of
SSI
No of
SSI
as %
Cumulative
ALL
Rate of
Hospitals
Infection % Cumulative
Rate of
Infection %
Hip
Oct –
Replacement Dec
2013
15
1
6.7%
6.7%
1.2%
Knee
Oct-Dec
Replacement 2013
31
0
0%
0%
1.7%
The above table depicts a high rate of infection at 6.7% for hip replacements at The Beaumont;
however this represents 1 patient/case. It is expected that as the site continues to collect,
analyse and submit data the cumulative rate of infection expressed as a % will come down to a
more comparative rate. This infection was treated very successfully with interactive dressings
and antibiotics; the patient did not require re-admission or return to theatre.
MRSA
In line with DH guidelines BMI The Beaumont screen all relevant NHS and private patients for
MRSA pre-operatively. Any patient identified as MRSA colonised is treated with MRSA
ϲͮW Ă Ő Ğ suppression therapies pre-operatively, their Consultant and GP informed and with effect from
September 2013 electronic markers are placed upon their BMI medical records. This alert
system brings us in line with BMI MRSA policy and provides a confidential and secure way of
communicating identified infection risks.
UTI’s
In February the site reviewed how it collects, stores and transports urine samples from clinical
area to laboratory in London. The Infection Prevention Nurse (IPN) reported that there were a
large number of reported urinary tract infections, resulting in some patients requiring antibiotics,
surgical interventions delayed/postponed or even cancelled. In line with good practice
guidelines the IPN introduced Boric Acid urine collection pots in February 2014 along with
training on collection and storage and the rate of reported urinary tract infections (UTIs) has
fallen dramatically. This has also reduced the number of patients treated with unnecessary
antimicrobials and subsequently the number of patients whose surgery was previously delayed
whilst the reported UTI was treated.
The following graph demonstrates the reduction in reported UTI’s from laboratory reports
between October 2013 and April 2014.
Care Bundles
Training has been provided to many clinical staff on care bundles/high impact interventions per
DH guidelines; however this project has yet to become embedded into practice. This is an ongoing project and it is anticipate that once the robust link worker cohort is established and
ϳͮW Ă Ő Ğ embedded within the site then this will become part of the quality assurance framework and
provide robust evidence of Infection, Prevention & Control (IPC) in action.
IPS Audits
Several audits have been conducted by the IPN over the past 12 months particularly:
•
•
•
•
•
•
IPS Quality Improvement Tool for Endoscopy
IPS Quality Improvement Tool for Decontamination
IPS Quality Improvement Tool for in-patient areas – ward
IPS Quality Improvement Tool for in-patient areas – physio
IPS Quality Improvement Tool for in-patient areas – hydro-therapy pool
IPS Quality Improvement Tool for cannula care/VIP charts
The results of these audits have been shared with the department managers and action plans to
address any issues have been developed and agreed. Full details are available on site.
In addition there have been a number of additional activities related to raising the infection
prevention profile and focus that have been conducted at The Beaumont Hospital including:
•
Water Safety
The facilities department at BMI The Beaumont Hospital has completed legionella water
testing within the last 12 months; all results were clear.
Per HTM 04-01 Pseudomonas Aeruginosa in Healthcare Settings, a local risk
assessment has been completed which demonstrates that there are no high risk areas
on this site therefore we do not require to conduct any water test for pseudomonas
aeruginosa.
Per CFPP 01-06: the endoscopy department conducts weekly final rinse water tests via
TEST Ltd. All results can be found within the Endoscopy dept., along with actions for
any reported concerns or failures. All concerns/failures have been processed per CFPP
01-06 guidelines & BMI Decontamination Policy.
•
Endo-Sheath Trial
BMI The Beaumont has led the way for the clinical trial and evaluation for a new system
for cystoscopy which it is hoped will provide a quicker more efficient service to patients
attending for cystoscopy procedures. In conjunction with the theatre team the IPN has
been involved in the escalation and communication with Corporate leads from
Decontamination, Microbiology and IPC Committee’s to ensure a quality and robust
service is maintained whilst innovation and technologies are utilised.
Initial evaluations by Consultant Urologists, staff and patients are all good and it is hoped
that this is something that will benefit all Hospitals within the group in the future
ϴͮW Ă Ő Ğ •
Sharp Safety
In line with EU Directive 2010/32/EU BMI The Beaumont Hospital has introduced
needle-safe devices wherever possible ensuring our cannula and venipuncture
equipment are now needle-safe. This has been led by the IPC service with training on
the new devices provided to key staff in clinical areas which has then been cascaded
within clinical teams.
In conjunction with our sharps bin provider (Daniels) there has been an annual audit of
our compliance with sharp bin practice, a summary provided by Daniels made the
following recommendations:
a) Train staff to put the temporary closure in place when
unattended or when moved
b) A one-brand system
c) Re-audit within one year
Training has since been provided by the IPN to staff at IPC training on sharps safety
including recommendation (a) above.
•
Education & training
IPC is included in the mandatory training requirements for all clinical and non-clinical
staff and incorporates e-learning, face-to-face interactive presentations and practical
assessments. In the past 12 months the IPN has delivered the following IPC training on
site:
•
•
•
IPC part 1 – introduction to IPC in the clinical areas, topics covered include hand
hygiene, chain of infection and sharp safety
IPC Care Bundles/High Impact Intervention
IPC Aseptic Non-Touch Technique – theoretical and practical training
ANTT practical assessments are required to be completed every 12 months and carried
out within the clinical areas (after staff have received the theory training) by peer review,
link staff or Clinical Managers.
•
Environmental cleanliness is also an important factor in infection prevention. During
the year the dedicated housekeeping staff has engaged with the clinical teams to ensure
that sufficient time and staff are available to maintain the high levels of cleanliness. The
following graphs taken from the patient satisfaction survey demonstrate that our patients
rate the cleanliness of our facilities highly.
ϵͮW Ă Ő Ğ 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
ϭϬͮW Ă Ő Ğ 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 Beaumont Hospital did complete the PLACE audit during 2013 however a full and detailed
report with scores is not currently available. From the data that is available a number of local
initiatives were implemented to enhance the service offering including:
-
-
Environmental - the creation of more waiting areas for patients attending for outpatient
clinics and those being admitted, increased signage from reception to a number of
outpatient based services on the ground floor and lift upgrade
Patient Safety – increased numbers of hand hygiene stations
Food services – a review of the food offerings has been completed a to support the
different pathways for patients undergoing treatments such as for Outpatient Walk-in,
Walk-out procedures, short stay admitted care procedures and for inpatients who stay
for a number of days
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 The Beaumont 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 who is admitted to our
facility and the results of our audit on this has shown that we achieved an overall compliance for
the full year of 96%. As a result a change in process was implemented after the first 3 months to
ensure that full compliance was achieved for the remainder of the year. In addition pharmacy
staff now provide an individual counselling session for all patients being discharged on
medication to ensure that patients and their relatives/carers fully understand the importance of
completing the course of treatment, how and when to administer the medication and are able to
discuss any concerns that they may have. To date this has received excellent feedback from
patients and the number of calls received by the hospital from patients after discharge with
questions and queries has reduced significantly.
ϭϭͮW Ă Ő Ğ VTE Risk Assessment (N3.1)
Description
of Indicator
Denominator
Numerator
Performance
% of all* adult inpatients who have had a VTE
risk assessment on admission to hospital using
the clinical criteria of the national tool
Number of adults* who were admitted as
inpatients (includes day cases, maternity and
transfers; both elective and non-elective
admissions)
Number of adult inpatient admissions reported
as having 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)
Target
95.80%
achieved
95%
BMI The Beaumont 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 incidents of DVT recorded during the year 2013 - 14 and the previous year
and the graph below visually demonstrates the significant reduction in incident rate over the last
2 year period
ϭϮͮW Ă Ő Ğ 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 The Beaumont Hospital. From the tables below,
it can be seen that our patients find that these operations beneficial to their well-being and
abilities post-surgery. This is evident with the hip and knee score health gain averages where
our reported post-operative health gain is only slightly under the national average. Now that we
have direct access to the data and are able to analyse at a patient level it is planned that the
relevant clinical teams will review this and identify opportunities to improve these outcomes.
Oxford Hip Score average
2012
Beaumont
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
England
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'
Oxford Knee Score average
2011/2012
Beaumont
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
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.
ϭϯͮW Ă Ő Ğ 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
There is a local team comprising of the physiotherapy manager, ward and theatre manager who
work collaboratively with other clinical managers and clinicians to review the current local
patient pathways on a quarterly basis. A significant amount of work has been focused over this
period on specifically reducing the length of stay for hip and knee replacement patients in line
with good practice by improving pre-operative physiotherapy and increasing patient ownership
and accountability of their rehabilitation programmes.
The chart below demonstrates this reduction in the length of stay over the last 5 year period for
all surgical cases at the hospital.
ϭϰͮW Ă Ő Ğ 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 has been a reduction in unplanned readmission rate over the last 5 years; this has been
due to a combination of factors inkling improved discharged process and the role that preassessment has had to ensure that only appropriate cases have been admitted to the
Beaumont Hospital for surgery.
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2.4 Unplanned Return to theatre
There has been a slight increase in the number of cases returning to theatre at the Beaumont
Hospital during the last year however a decrease over the last 5 year period. A contributory
factor in this has been the increase in the level of pre-assessment that has been carried out at
the hospital which has resulted in improved pre-operative management of surgical cases at the
hospital. This will continue to be a focus over the next year with an aim to continue to ensure
ϭϱͮW Ă Ő Ğ that clinical risk assessment is carried out for all patients planned to have a surgical procedure
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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 following table demonstates that patient satisfaction acorss 6 categories have increased
substantially above the results for 2013 and above the levels achieved in 2012. This has been
as a direct reuslt of the management team leading a patient focussed review of internal
processes and care delivery from all hospital staff. This plus the development and
implementation of customer care training will continue to be a focus over the coming year.
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
The Beaumont 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.
ϭϳͮW Ă Ő Ğ The table below shows the incidence of written complaints at the hospital over the last 5 year
period. There has been a reduction in the number of complaints received over recent years with
the exception of this year wich shows an increase in 2014. In some part this is as a result of an
increased focus to ensure that all complaints are registered on the hospital’s quality
management system and a strategy with all staff that patients providing feedback is an
important and useful way to assess our services.
Whilst detail of all complaints is held at site, 2 main themes from this period were related to
communication issues and lack of car parking facilities at the hospital. As a result of these there
has been a renewed focus on ways of working between teams to ensure that all relevant
information is shared; this review has included administrative staff in addition to clinical so that
the whole team has been involved. In addition there has been a change in car parking
management which came in to effect from January 2014 with a significant number of staff now
parking at an offsite facility. Patient surveys have already started to show a reduction in
comments and concerns related to this issue.
There have been 0 complaints from this period escalated to stage 2.
ϭϴͮW Ă Ő Ğ 4. CQUINS
In 2013 / 2014 BMI the Beaumont Hospital achieved CQUINS in the following areas:
Friends and Family Test (20% by Q4)
VTE risk assessment (Target 95%)
VTE incidences root cause analysis
NHS Safety Thermometer
Best practice use of catheters.
Achieved
24.14%
95.8%
100%
100%
99.2%
The Hospital also made some progress in the implementation of providing patients with a Post
Discharge telephone call achieving 87.3%
5. National Clinical Audits
BMI the Beaumont Hospital was only eligible to participate in National Joint Registry audit and
all joint replacements are submitted to this. The following summary table graphically
demonstrates the 4 quarters for the year.
NJR Summary Data BMI Healthcare - BMI The Beaumont Hospital - 2013
The total number of operations performed is predominantly made up of knee and hip
replacements with only 1 shoulder replacement and no ankle replacements. The graph
demonstrates that the increase in procedures were performed in Quarters 3 and 4 data shows
an increase in the number of operations performed at BMI the Beaumont Hospital and a slight
reduction in the consent rate however the average consent rate for the year was 89%. The PreAssessment nurses discuss participation in this audit with all relevant patients at the individual
appointments and there have been no specific reasons identified for this reduction however as a
result, a review of this process is underway to identify opportunities to return the consent rate
back to above 90%. In addition the Pre-Assessment nurses are working to discuss participation
in this audit with all shoulder, ankle and elbow replacement patients.
ϭϵͮW Ă Ő Ğ 6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
The Beaumont Hospital focus for service development and improvement include:
- Improving patient pathway for MSK referrals by reducing the waiting list for NHS patients
requiring physiotherapy
- The development of a static MR Scanner within hospital
- The development of additional outpatient based procedures where clinically appropriate.
1 example of this under review is being able to perform flexible sigmoidoscopies
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Beaumont Hospital for the reporting period.
Unit
0
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
The Beaumont Hospital is not able to report specifically on this indicator to compare as the
HSCIC data does not contain the independent sector for this however data is available for the
site. There have been 0 reported peri-operative mortality (expected and unexpected) at the
hospital.
8.2 The Beaumont Hospitals patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.022
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
The Beaumont Hospital considers that this data is as described for the following reasons: a
small number of this type of procedure performed at the hospital.
The Beaumont Hospital has ensured that the local community is aware that this type of surgery
is offered at the hospital and will continue to ensure that this is included in any marketing
material and on the website.
ϮϬͮW Ă Ő Ğ (ii) Varicose vein surgery
Unit
No data
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
-8.738
8.172
-15.918
There has been no data provided for varicose vein surgery which is undertaken by The
Beaumont Hospital and therefore are not able to provide any narrative.
As a result The Beaumont Hospital will continue to ensure that the local
community/commissioners are aware that this type of surgery is offered at the hospital through
a variety of communication methods.
(iii) Hip replacement surgery
Unit
*
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
21.280
24.684
17.214
The Beaumont Hospital considers that this data is as described due to insufficient patient
numbers which is surprising due to the number of hip replacements that are performed at the
hospital. This is supported by the participation in the NJR audit and therefore this cannot be
explained by the site.
(iv) Knee replacement surgery during the reporting period.
Unit
16.285
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 Beaumont Hospital data is reported as being above the national average but lower than the
highest national score.
The Beaumont Hospital physiotherapy lead will continue to review this data now that it is more
readily available and therefore will be able to review the patient pathways and identify potential
opportunities to further increase the score.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
Beaumont Hospital within 28 days of being discharged from a hospital which forms part of the
hospital during the reporting period.
ϮϭͮW Ă Ő Ğ 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
As the Beaumont Hospital does not admit any patients who are under 16 years old there is a
score of 0 for readmissions for this patient category and therefore there are no actions required.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the Beaumont Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
No data
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
The Beaumont Hospital is unable to provide a detailed comparative reconsiders that this data is
as described as the quality management system is not able to differentiate readmissions by
age.
The following graph does however demonstrate a significant reduction in all unplanned
readmission rate over the last 5 year period which would support the high standards of clinical
care and discharge process that are delivered at the hospital.
ϮϮͮW Ă Ő Ğ The Beaumont Hospital has reviewed the Pre-Assessment process and documentation during
the last 12 months which has resulted in patients being prepared and where necessary
preoptimised for surgery so reducing the potential for complications post operatively. Formal
anaesthetic assessments are performed by a consultant anesthetist in the event that any
patients are identified as potentially high risk to ensure that it is safe to provide the surgery at
the hospital. In addition to this enhanced written guidance/reference sheets are provided to the
patients before the day of admission to support the verbal information provided to them at the
appointment including detailed information of the procedure to be undertaken, the type of
anaesthetic they will be having and pain management.
8.4 The Beaumont Hospitals responsiveness to the personal needs of its patients during the
reporting period.
Unit
94.98
Reporting Periods
(at least last two
reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
The Beaumont Hospital is pleased to report that the reported score is 10.58 points above the
highest national score and demonstrates the patient centred approach of all care delivery that is
offered within the hospital.
The Beaumont Hospital will continue to ensure that patients remain at the centre of the care
delivery process through a variety of different approaches including customer care training,
patient allocation and appropriate levels of staff to patient ratios in all areas where care is
delivered.
8.5 The percentage of patients who were admitted to The Beaumont Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
96%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
The Beaumont Hospital collects this data on a monthly basis for patients admitted to the
hospital for a procedure undertaken in the theatre suite and is pleased to report an overall score
of 98% compliance. A number of local initiatives have been undertaken to ensure that this high
level of compliance is maintained through staff education and training and all staff participating
in the audit programmer
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Beaumont
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
ϮϯͮW Ă Ő Ğ The Beaumont Hospital is pleased to report a rate of 0 and considers that this data is as
described due to admissions policy and screening processes in place plus the environment,
training of all staff in infection control and the high standards of cleanliness that exist within the
hospital. This will continue to be a focus during the next year.
8.7 The number and, where available, rate of patient safety incidents reported within the
Beaumont 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
94
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Mar 14
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
4.11
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
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
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
0.0
The graph below graphically demonstrates that there have been 0 serious incidents in 2014 and
over the previous 3 year period at The Beaumont Hospital.
ϮϰͮW Ă Ő Ğ The Beaumont Hospital has a very clear focus on ensuring patient safety which is supported by
a robust and thorough clinical risk assessment that is completed either before or at admission
for all patients admitted for surgical and medical treatment.
The hospitals clinical strategy which is regularly reviewed has a focus on patient safety and the
delivery of effective clinical care will cotinine to ensure that this remains a priority at The
Beaumont Hospital.
8.8 The percentage of staff employed by The Beaumont Hospital during the reporting period,
who would recommend the The Beaumont as a provider of care to their family or friends.
Unit
87
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
The score for The Beaumont Hospital has been collected via a specific staff survey of which
87% of hospital staff reported that they would recommend the hospital as a provider of care to
their family and friends. This was a very high score within BMI Healthcare.
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 The Beaumont Hospital as a provider of care
to their family or friends.
Unit
N/A
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
As The Beaumont Hospital does not have an A & E facility this indicator is therefore not
applicable.
ϮϱͮW Ă Ő Ğ