Blackheath Hospital/Quality Accounts/May 2014 1

BMI Blackheath 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 Com mission’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 ag ree 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 Today that work has been superseded by the Private Hospitals Information Network which is working towards publishing data that will allow patients and commissioners to make informed choices - a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
Blackheath Hospital/Quality Accounts/May 2014 2

Hospital Information
The Blackheath Hospital is a 68 bedded facility located in Blackheath Village, well serviced by transport links.
The beds are located in 2 wards; most of the rooms are single with en suite facilities, and there is a 3 bedded High Dependency Unit contained within the ground floor ward, and a dedicated endoscopy unit.
Blackheath offers a broad range of surgical specialties, such as orthopedic, neurological
(spinal), gynecology, and urology, colorectal and general surgery.
A theatre refurbishment programme began in September 2013 and is on course to complete by the end of May 2014; this has given us 3 state of the art theatres [2 with laminar flow] and a 6 bedded recovery area.
Approximately 25% of our patients are NHS patients through the Choose and Book scheme.
Our management team is in close communication with the local commissioning boards, and participates in CQUINS and other quality indicators.
Blackheath Hospital/Quality Accounts/May 2014 3

BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Blackheath Hospital is registered as a location for the following regulated services:-
· Treatment of disease, disorder and injury
· Surgical procedures
· Diagnostic and screening
· Termination of Pregnancy
· Family Planning
The CQC carried out an unannounced inspection on 06 November 2013 and found non compliances with 3 of 6 outcomes; two were considered to be of minor impact, and one of moderate. As a result the Blackheath are working according to a stringent action plan to resolve issues found.
Outcome and CQC Judgment following unannounced inspection of 06 November 2013
Met this standard
Action needed
Action needed
Met this standard
Met this standard
Action needed
Blackheath 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.
Blackheath Hospital/Quality Accounts/May 2014 4

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.
Additionally at Blackheath incident reporting is an ongoing item on the Induction Training day available to all staff, and staff are also offered one to one training sessions with the Quality and
Risk Manager or Coordinator.
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.
1.1 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 Blackheath Hospital.
We have had: -
· Zero cases of MRSA bacteraemia in the last year
(NHS 1.17cases/100,000 bed days).
· MSSA bacteraemia cases /100,000 bed days
· E.coli bacteraemia cases/ 100,000 bed days
· Zero incidents 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;
Blackheath Hospital/Quality Accounts/May 2014 5

Number of Hip and Knee Replacements from April 2013 to March 2014
Hip Replacements Knee Replacements
51 85
During this period, 2 surgical site infections were identified. In both cases, the patients made a good recovery with appropriate therapy.
Surgery Organism
1. Knee Replacement
2. Hip Replacement
Total percentage of Surgical
Site Infections for Hips and
Knees at Blackheath Hospital for this period.
Blackheath Hospital follows a corporate audit calendar as follows:
This audit is a large yearly audit covering the site as a whole. A monthly audit with a focus on different elements of IPC.
Occurrence
Staphylococcus Aureus
Escheria Coli
HIPS = 1.9%
KNEES=2%
Yearly
Yearly
Yearly
Yearly
Audit
Patient bed Mattress integrity
Outcome/actions
88% Compliance
Need to ensure all mattress covers are labelled with a number and the date on which they were fitted.
Compliance with cleaning schedules 91% compliance
Sign off of schedules were not always
Personal Protective Equipment
Sharps Safety Management completed-this has been addressed.
100% compliance
85 % compliance
Lower compliance due to two sharps buckets being filled slightly beyond the acceptable mark.
This was fed back to staff and local departmental audits have shown that this has ceased; however an overall hospital audit will be carried out in May 2014.
Twice Yearly
Waste Management 100% compliance
On 02 May 2014 the Infection Prevention and Control Nurse facilitated a Handwash Day; staff washed their hands and was then inspected under an ultra violet lightbox. They also participated in a quiz, and clinical staff completed their infection control competencies.
Blackheath Hospital/Quality Accounts/May 2014 6

Departmental IPC Links are responsible for monthly environmental audits, which focus on the following areas :
General Management/staff training/policies & procedures
General environment/rooms;
Clean Utility
Dirty Utility
Large store room
Sharps Management.
PPE.
Waste Management
Linen management
Equipment
Waste management
Pantry
Hand hygiene
Feedback from the audits has resulted in the refurbishment of one of the sluice rooms since it was consistently overcrowded. The bedpan washer has been decommissioned and a macerator is being fitted.
Intra operative High Impact
Interventions
Post operative high impact interventions
Pre operative High Impact
Interventions
100% compliance with
Skin preparation
Administration of antibiotics
Incise drapes
Supplemented Oxygen
Glucose Control
82% compliance
Normothermia control with
82% compliance with surgical site dressing practice
100% compliance with pre op showering and hair removal
Bair Huggers applied to patients in theatre
Care pathway documentation being reviewed to facilitate better documentation
Improvements required in hand hygiene in accordance with WHO 5 moments
91 % compliance with MRSA screening; this continues to be audited on a monthly basis for the purposes of CQUINs data, and so that trends can be identified
Blackheath Hospital/Quality Accounts/May 2014 7

IPC Training
68% of assigned Blackheath Staff completed their Infection Prevention and Control E Learning module, which incorporated ANTT and Care Bundles.
Two senior clinical staff will be attending ‘Train the Trainer’ training on Aseptic Non
TouchTechnique in June 2014, and will cascade this training back to Blackheath staff.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly.
Blackheath Hospital/Quality Accounts/May 2014 8

1.2 Patient Led Assessment of the Care Environment (PLACE)
In 2013 Blackheath Hospital performed its first PLACE audit [Patient Led Assessment of The
Care Environment]. The 2014 audit was completed 14 March 2014, with results to be published on The Department of Health website September 2014.
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.
The assessments involve patients and staff who assess the hospital and how the environment supports pa tient’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.
Blackheath Hospital/Quality Accounts/May 2014 9

In May 2014 the Blackheath Oncology Unit was inspected by The Macmillan Team with a view to obtaining the Macmillan Quality Environment Mark. The written report is awaited, but the initial report is extremely positive, giving us an overall score of 5. The judgement framework is based on the following indicators
·
·
·
·
· welcoming and accessible to all respectful of people's privacy and dignity supportive to users' comfort and well-being giving choice and control to people using your service
Listening to the voice of the user.
Venous Thrombo-embolism (VTE)
BMI Healthcare holds VTE Exemplar Centre status by the Department of Health across its whole network of hospitals including Blackheath 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 100% compliance. We aim to maintain this score by means of our monthly audits; the result of these are a fixed agenda item for our monthly CET meetings. In this way we can quickly pick up any reductions in compliance and act on them swiftly.
Blackheath 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. We have not had any reports of DVT [Deep vein thrombosis] during the last year.
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 are a Department of Health led programme.
Currently not enough completed questionnaires are being sent to the company who collate our returns; going forward this will be added to our Patient Satisfaction Plan [Appendix ii] so that we can ensure robust data collection. Currently the amount of returns received is insufficient for the amount of data required.
Blackheath Hospital/Quality Accounts/May 2014 10

We are working towards improving the patient experience and outcomes at Blackheath in a number of ways; we now have a dedicated Enhanced Recovery Group [ERP] focusing on reduced inpatient stay and improved mobility for hip and knee replacement patients.
Our PAC [Pre Admission Clinic] sees all patients undergoing hip and knee replacements and start discharge planning at that stage. Blackheath Physiotherapy Department has started to offer pre op joint schools so that patients reach optimum mobility standards.
We are also developing external links with social services so that we can have community support in place for patients who need it on discharge. This can be difficult since our local council will not take referrals until the patient is an in patient, thus delaying discharge home. In order to tackle this problem one of our in patient Sisters is developing a Discharge Resource
Folder and building up links with local social services and personal care providers. Regional
BMI Pre Assessment Nurses are now meeting on a regular basis, and one of the primary objectives will be the emphasis on discharge planning at pre assessment clinics.
Oxford Hip Score average
2012
Q1 Q2 Health gain (Q2 - Q1 average)
Blackheath Insufficient data
Hospital
0.339
0.767
0.429
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
Q1 Q2 Health gain (Q2 - Q1 average)
Blackheath
Hospital
Insufficient data
0.387
0.709
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
2.2 Enhanced Recovery Programme (ERP)
0.321
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.
Blackheath Hospital/Quality Accounts/May 2014 11

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
Blackheath ERP group comprises of members of all disciplines working together to achieve success with the ERP. Carbohydrate loading will be trialed, and the
Physiotherapy department is offering pre admission joint schools to all hip and knee replacement patients.
We are currently auditing length of inpatient stays for our hip and knee replacement patients so that we can identify any trends which may be affecting length of stay. The team works to an ongoing action plan.
2.3 Unplanned Readmissions within 31 days and unplanned returns to theatre.
Unplanned readmissions and unplanned returns to theatre are usually due to a clinical complication related to the original surgery.
For Blackheath the statistics are as follows, and are well within national parameters:
Unplanned return to theatre rates 0.289
0.139 % Unplanned readmission rates
Based on patient bed days
Blackheath Hospital/Quality Accounts/May 2014 12

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.
Admission
Nursing
2012
% Good or Excellent
93.6
93.8
2013
% Good or Excellent
94.8
94
Accomodation
Catering
Departure
Overall Quality of Care
89.6
97.2
96.8
97.0
91.2
85.2
87.3
96.1
Patient satisfaction results reports are received monthly. The results are disussed at the monthly Heads of Department meetings, and cascaded down to the departmental dtaff by the
Heads of Department via their Team Brief.
Since April 2014 Blackheath Hospital have been participating in a pilot for online patient satisfaction surveys; it is hoped that this will improve our return figures. We aim for returns of at least 20 % [of patient comletion] We encourage participation by feeding back actions taken based on previous satisfaction results, so that the worth of participating is clear. Examples are the creation of a designated garden space for patients, and a complete review of the way food is servied to the patients.
Blackheath Hospital deliver monthly Customer Engagement Training Days, which is mandatory for all staff. The training is delivered by 2 members of staff who were trained by an external company.
The objective of the course is to support staff to engage effectively with customers, creating positive customer experiences and an inclusive, cooperative hospital environment
All pertinient issues from satisfaction surveys, complaints, incidents, 48 hour follow up calls and any other type of feedback are incorporated intio the hospital patient sdatisfaction plan. This can be viewed by all on the shared drive.
Blackheath Hospital/Quality Accounts/May 2014 13

3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Blackheath 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.
Blackheath Hospital Complaints 2013-2014
During this period, the percentage of written complaints [based on per 100 admissions] was
0.14120305, which is very low in comparison to hospitals of similar size and activity.
30% of the complaints were upheld by the Executive Director
Billing and charges
Medical and nursing care/treatment
34%
30%
Administration/written communication
Environment [car parking]
26%
10%
The complaints regarding billing and charging are mainly made by insured patients who are required to make payments for insurance shortfalls. Blackheath attempt to forewarn patients as far as possible by a poster campaign in Outpatients, as well as asking the patient to read and sign the terms of registration.
Complaints about nursing care and medical treatment mainly involve poor communication and failure to keep patients informed. The In Patient manager has developed a detailed handover sheet to ensure that all relevant information is handed over from shift to shift, and that nursing staff are aware of the overall patient management plans.
Any nursing staff involved in complaints take part in the investigation, and receive extra training as appropriate.
Issues involving consultants are managed by the ED or Director of Nursing, supported by the
Medical Advisory Committee.
Changes have been made to the Bookings and Appointments department in response to previous complaints and booking problems-complains and incidents concerning this topic have fallen in recent months, with only 08% of complaints in Jan-Mar 2013 connected to administration problems.
Car parking will always present problems in an urban area, but Blackheath have made attempts at more robust management: a new parking control contractor was appointed in April 2014, the car parking bays have been freshly painted, and an area of the car park in the Outpatient
Department is closed after a certain period to prevent illicit overnight parking.
Blackheath Hospital/Quality Accounts/May 2014 14

Patient complaints issues are discussed at the monthly Heads of Department meetings and cascaded back to the departmental staff via the Team Brief and departmental meetings. Issues are incorporated into the Blackheath Patient Satisfaction Action Plan.
An update on current complaint rates and themes are fixed items on the Blackheath induction and mandatory training days. Feedback from staff informs the action plan mentioned above.
4. CQUINS[Commissioning for Quality and Innovation]
From April 2013-March 2014 Blackheath Hospital have reported compliance with the following for the purposes of CQUINS reporting:
CQUINS criteria have changed over the last year;the table below indicates the period
From Jan-March 2014
CQUINS Indicator Compliance Actions
Patient screening for MRSA 100%
Nutritional Screening for patients on admission
98.6%
Smoking Cessation information for patients
98%
Admission screening for VTE 100%
Appropriate VTE Prophylaxis given 100%
We will maintain this by ensuring all staff are aware of the local MRSA screening policy and by acting on any reduction in compliance
We will ensure all relevent staff are aware of the process, and by investigating any lapses in compliance. Our [currently 3 times a week] audit of documentation should highlight any trends or staff involved in non compliance,.
Training of staff to ensure that all patients are offered this information as part of the routine registartion process
We will maintain this by ensuring staff are aware of the evidence behind this requirement, and by analysing our documentation audits to identify any trends/staff involved. The VTE link nurse to deliver workshops information on VTE and prophylaxis.
As above; additionally any VTE episodes would be subject to a stringent root cause analysis.
Blackheath Hospital/Quality Accounts/May 2014 15

Friends and Family Test 95.7%
We will work on improving these figures by delivering and monitoring good care to our patients, acting on feedback they give to us. All Blackheath staff will now complete a Customer Engagement training day.
Information taken from complaints, 48 hour phone call feedback, incidents and patient satisfaction results will inform our patient satisfaction action plan, and be fed back via monthly Heads of Department meetings and cascaded to staff via Team Briefs and
Departmental meetings.
Safety Thermometer
This records:
· Prevention of Urinary Tract
Infections
· Prevtion of falls
· Prevention of VTE
100%
We will continue to maintain compliance by means of auditing and monitoring, and conducting a Root
Cause Analysis if any incidents do occur.
Care Bundle Audit-To increase best practice use of catheters - percentage of patients receiving peri-operative and post-operative catheter care where appropriate.
83.6%
Use of care pathways is now an agenda item on the local induction training day.
Regular documentation audits by the QRM will identify trends/staff involved. The Practice
Development nurse will then work with relevcnet staff on a 1:1 BASIS.
5. National Clinical Audits
Blackheath 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 196 onwards in attached latest NJS report. Use this if appropriate with your narrative on the data and any improvement plans.
6. Research
No NHS patients were recruited to take part in research.
Blackheath Hospital/Quality Accounts/May 2014 16

7. Priorities for service development and improvement
· Refurbishment of Theatres and upgrade from 3 to 6 recovery beds [due for completion May 2014]
· Building of Critical Care Unit
· Development of Interventional Radiology suite
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Blackheath Hospital for the reporting period.
Reporting Periods
Unit (at least last two reporting periods)
National
Average
Data not available Value and
Banding
Highest National
Score
Lowest National
Score
8.2 The (name of hospital ’s ) patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Number Data not currently collected for this.
(ii) Varicose vein surgery
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Number Data not currently collected for this
The (name of hospital) considers that this data is as described for the following reasons (insert reasons).
Blackheath Hospital/Quality Accounts/May 2014 17

(iii) Hip replacement surgery
Reporting Periods
Unit (at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Q2, 2013
Number-4 questionnaires submitted
Q4,2012-1 questionnaire submitted
Number of returned questionnaires not sufficient for meaningful data analysis
The Blackheath Hospital considers that this data is as described because we are not receiving enough completed questionnaires
How we plan to improve on this:
· Method of distribution of questionnaires will be reviewed, along with the information given to the patient at the time
· Add this issue to the hospital quality improvement plan
· More frequent monitoring of returns so that poor participation can be picked up earlier
(iv) Knee replacement surgery during the reporting period.
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Q3, 2013-total of 3 questionnaires returned
Q4, 2013-4 questionnaires returned
The Blackheath Hospital considers that this data is as described due to insufficient returns.
How we plan to improve on this:
· Method of distribution of questionnaires will be reviewed, along with the information given to the patient at the time
· Add this issue to the hospital quality improvement plan
· More frequent monitoring of returns so that poor participation can be picked up earlier
(v) Knee replacement surgery during the reporting period.
Blackheath Hospital/Quality Accounts/May 2014 18

8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
Blackheath hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period.
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
% n/a we do not treat this group
8.3.(ii)The percentage of patients aged 16 or over readmitted to a hospital which forms part of the Blackheath hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period.
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
0 %
0 %
Q4 2013
Q2 2013
The Blackheath hospital considers that this data is as described for the following reasons (insert reasons).
8.4 The Blackheath hospital ’s responsiveness to the personal needs of its patients during the reporting period.
Reporting Periods
Unit (at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Q1 2013
Q2 2013
99 %
93%
‘ Hospital staff being available to discuss patients’ needs/concerns ’
Blackheath Hospital/Quality Accounts/May 2014 19

72
54
The Blackheath Hospital plan to maintain high end scores by continued focus on patient satisfaction and patient engagement. This will be a topic on induction days, monthly mandatory training, and mandatory customer engagement workshop days.
8.5 The percentage of patients who were admitted to (name of hospital) and who were risk assessed for venous thromboembolism during the reporting period.
Reporting Periods
Unit (at least last two reporting periods)
National
Average
Highest National
Score
100%
100%
Q1 2014;
Q4 2013-
Lowest National
Score
The Blackheath hospital considers that this data is as described for the following reason:-
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Blackheath hospital amongst patients aged 2 or over during the reporting period.
Unit
Reporting Periods
(at least last two
National
Average
Highest National
Score reporting periods)
Rate-0% Q1 2014;Q4 2013-0%
Lowest National
Score
8.7 The number and, where available, rate of patient safety incidents reported within the
Blackheath 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
Reporting
Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
Number
Q1 2013
Q2 2013
Blackheath Hospital/Quality Accounts/May 2014 20

Rate of patient safety incidents reported
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Rate
2.146
3.058
Q 1 2013
Q2 2013
Highest National
Score
Number of patient safety incidents that resulted in severe harm or death
Unit
Reporting Periods
(at least last two reporting periods)
Q1 2013
National
Average
Highest National
Score
Numbernil
Q4 2013 Numbernil
Percentage of patient safety incidents that resulted in severe harm or death
Reporting Periods
Unit (at least last two reporting periods)
National
Average
Highest National
Score
0%
0%
Q1 2013
Q2 2013
Lowest National
Score
Lowest National
Score
Lowest National
Score
8.8 The percentage of staff employed by the Blackheath Hospital during the reporting period, who would recommend it as a provider of care to their family or friends.
Unit
%
Reporting Periods
(at least last two
National
Average
Highest National
Score reporting periods)
Insufficient data available to complete this section
Lowest National
Score
Blackheath Hospital/Quality Accounts/May 2014 21

9.1 The percentage of patients who received care as inpatients or discharged from A &E during the reporting period, who would recommend the (name of hospital) as a provider of care to their family or friends.
Unit
Reporting Periods
(at least last two reporting periods)
National
Average
Highest National
Score
Lowest National
Score
95.7%
99 %
Q1 2013
Q1 2014
Blackheath Hospital/Quality Accounts/May 2014 22