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BMI Cavell Hospital Quality Accounts
April 2013 to March 2014
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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 Today that work has been superseded by the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.
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Stephen Collier
Chief Executive Officer
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Cavell Hospital Information
BMI The Cavell Hospital is located in
Enfield approximately half a mile from
its sister hospital, The King’s Oak. It
has 28 beds with all rooms offering the
privacy and comfort of en-suite
facilities, satellite TV and telephone.
The hospital has a fully equipped High
Dependency unit (level 2), 2 Operating
Theatres, and Minor ops room, MRI
and CT Unit, and brand new
Endoscopy suite (opening mid 2014).
In 2013, 45% of overall work at Cavell
Hospital was undertaken on NHS
patients.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Cavell 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 4th February 2014 and examined the
following standards.
Care and welfare of people that use services
Meeting nutritional needs
Safety, availability and suitability of equipment
Assessing and monitoring the quality of service provision
Complaints
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9
9
9
9
9
Met this standard
Met this standard
Met this standard
Met this standard
Met this standard
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Cavell 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 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.
There are external reporting requirements for CQC, Public Health England (Previously HPA)
CCGs and Insurers. There has also been ongoing progress on the project to collect and publish
comparative data to assist patients and referrers with their choices on healthcare facility. This
has started with the launch of an independent Private Healthcare Information Network website
ŚƚƚƉ͗ͬͬǁǁǁ͘ƉŚŝŶ͘ŽƌŐ͘ƵŬ This provides information on facilities, numbers of a variety of
procedures carried out at each site and some basic quality indicators. The range of the available
indicators will continue to grow for ongoing enhancement of choice.
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 Cavell Hospital.
We have had zero cases of MRSA bacteraemia in the last year
(NHS 1.17cases/100,000 bed days), zero MSSA bacteraemia
cases/100,000
bed
days,
zero
E.Coli
bacteraemia
cases/100,000 bed days, and zero cases of hospital
apportioned Clostridium difficile in the last 12 months.
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SSI data is also collected and submitted to Public Health England for orthopaedic surgical
procedures. Our rates of infection for 2013/4 are:o Hips – 0
o Knees – 0
1.1 Infection prevention and control (continued):
Audits have been undertaken in Sharps safety, Inpatient Management, Management of
equipment, and mattresses which have all achieved scores of 82% and above.
Care bundles have also been implemented on the wards and in theatres around peripheral
cannula insertion and care, urinary catheter insertion and care, and surgical site infections,
again with very high results.
Furthermore, Hand hygiene and Asceptic Non-Touch Technique (ANTT) training is now
included in the hospital’s mandatory practical infection prevention and control training.
Environmental cleanliness
is also an important factor in
infection prevention and our
patients rate the cleanliness
of our facilities highly.
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 a new system for assessing the quality of the patient
environment, replacing the old Patient Environment Action Team (PEAM) 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
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focuses entirely on the care environment and does not cover clinical care provision or how well
staff are doing their job.
The PLACE audit for Cavell Hospital was carried out in May 2013 and involved four patient
assessors and four staff split into 2 teams, with results as follows:Cleanliness
Food
Privacy, Dignity &
Wellbeing
Condition, Appearance
& Maintenance
93.75%
87.56%
87.10%
91.11%
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, Cavell Hospital, BMI Healthcare won the Best VTE
Education Initiative Award category of the Lifeblood VTE Awards in February 2013 and were the
Runners up in the Best VTE Patient Information Structure category.
We see this as an important initiative to further assure patient safety and care. We audit our
compliance with our requirement to VTE risk assessment every patient and the results of our
audit on this has shown 100%. We intend maintain this result through continued focus on it
through our monthly Clinical Days, and through monthly auditing.
Cavell Hospital reports the incidence of 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. These figures show that
VTE incident numbers remain very low. In 2013/14 VTE rates were 0.06% of total cases at
Cavell Hospital (2 VTEs). Both were investigated - had risk assessments carried out, and
received appropriate prophylaxis.
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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.
April 12 – March 13:
Oxford Hip Score Average
Hospital
England
Oxford Knee Score Average
Q1
Q2
Health gain average
between reporting
periods
17.5
42.571
25.071
16.944 34.722
17.778
17.907 39.224
21.317
18.893 34.902
16.01
Q1
Q2
Health gain average
between reporting
periods
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) Optimising the patient prior to admission – i.e. HB optomisation, control comorbidities, medication assessment – stopping medication plan
d) Commencement of discharge planning
3. Proactive patient management
a) Maintaining good pre-operative hydration
b) Minimizing the risk of post-operative nausea and vomiting
c) Maintaining normothermia pre and post operatively
d) Early mobilisation
4. Encouraging patients to have an active role in their recovery
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a)
b)
c)
d)
Participate in the decision making process prior to surgery
Education of patient and family
Setting own goals daily
Participate in their discharge planning
At Cavell Hospital, ERP is monitored on a daily basis at HoDs Ops meeting with the
Physiotherapy Manager leading on this.
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.
Cavell Hospital Re-admission and Returns to Theatre Rates 2013/4
No trends for concern have been identified, and there is ongoing monitoring, analysis and
review by the Risk & Governance Committee on a quarterly basis to ensure that appropriate
action is taken is required to minimize the risk of complications.
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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.
All areas have shown progress over the 2 year period, but the management team are constantly
seeking ways of improving further. At each monthly Heads of Departments meeting, patient
satisfaction is discussed – particular areas of focus are arrival, catering and the patient
discharge process. A Patient Satisfaction Focus Group evening was held in November where
patients were invited to discuss various issues around their stay, which proved very useful in
directing improvements. Another is planned for June 2014.
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
ĂǀĞůů,ŽƐƉŝƚĂů 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.
Every complaint is thoroughly investigated, and a written response sent to the complainant.
Lessons to be learnt are sought through each investigation to prevent recurrence and improve
quality of care. In the reporting period, there were 0 complaints that went to stage 2.
4. CQUINS
Cavell Hospital took part in CQUINs for North Central London, and East of England. VTE risk
assessments, the Friends and Family test, the Safety Thermometer, and Catheter Care Bundles
were monitored for both, with additional audits on Smoking Cessation, and Nutritional
Assessments carried out for London; and Post-Surgical Follow-up, and Lifestyle Intervention
Audit (raised BMI) carried out for East of England. All CQUINs were achieved last year.
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5. National Clinical Audits
Cavell 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
•
On-going engagement with NHS commissioners to enhance patient choice and service delivery
to NHS patients will be measured by agreed quality indicators
•
Audit compliance with Care Bundles to ensure that these have been effectively implemented and
this will be measured by infection rates.
•
Extension of collection of PROMS to include hip and knee replacement all patients.
•
Plan to open new Endoscopy suite and achieve JAG accreditation to be able to expand service
provision to local community.
•
Rolling out 6C’s programme
8. Mandatory Quality Indicators
8.1
The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Cavell Hospital for the reporting period.
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
Value and
Banding
Oct 11 – Jun 13
1.0006
1.1822
0.6735
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8
Mandatory Quality Indicators (continued):-
8.2
The Cavell Hospital’s patient reported outcome measure scores for:i) Groin Hernia Surgery:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
*
Apr 12 – Mar 13
0.083
0.157
0.014
*There were less than 30 patients going through the process for groin hernia surgery so
Cavell Hospital was unable to be scored on this element.
The Cavell Hospital intends to take the following actions to improve this score, and so the
quality of its services by documenting every patient that is asked to complete PROMs –
most are asked, but decline.
ii) Varicose Vein Surgery:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
NA
Apr 12 – Mar 13
Apr 12 – Mar 13
-8.738
8.172
Please note that the data provided by HSCIC did not give any data in terms of Varicose
Veins and therefore none can be reported. There were no scores for varicose veins for
BMI Healthcare and there none of the hospitals can be scored for this.
iii) Hip Replacement Surgery:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
*
Apr 12 – Mar 13
21.280
24.684
17.214
*There were less than 30 patients going through the process for hip replacement surgery
so Cavell Hospital was unable to be scored on this element.
The Cavell Hospital intends to take the following actions to improve this score, and so the
quality of its services by documenting every patient that is asked to complete PROMs –
most are asked, but decline.
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8
Mandatory Quality Indicators (continued):iii) Knee Replacement Surgery:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
*
Apr 12 – Mar 13
15.99
20.37
12.2
*There were less than 30 patients going through the process for knee replacement
surgery so Cavell Hospital was unable to be scored on this element.
The Cavell Hospital intends to take the following actions to improve this score, and so the
quality of its services by documenting every patient that is asked to complete PROMs –
most are asked, but decline.
8.3
i) The percentage of patients aged 0-14 readmitted to Cavell Hospital within 28 days of
being discharged during the reporting period:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
0.03%
Apr 11 - Mar 12
11.45
14.35
7.96
This figure is well below the national average. Readmission figures are reviewed by the
hospital Risk and Governance Committee on a quarterly basis to monitor for any adverse
trends, and appropriate action taken as necessary.
ii) The percentage of patients aged 15 or over readmitted to Cavell Hospital within 28 days
of being discharged for the reporting period:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
0.41%
Apr 11 - Mar 12
10.01
14.51
5.54
Again, this figure is well below the national average. As above, readmission figures are
reviewed quarterly. If necessary, the patient’s notes will be review to ensure that all
discharge criteria were met at the time of going home – this was the case for all readmissions during the reporting period.
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8
Mandatory Quality Indicators (continued):-
8.4
The Cavell Hospital’s responsiveness to the personal needs of its patients during the
reporting period:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
93.05%
2012-2013
68.1
84.4
57.4
This figure is well above both the national average and the highest national score.
A continued focus on patient satisfaction will be maintained to ensure that these high
scores and so the quality of Cavell’s services will be achieved.
8.5
The percentage of patients who were admitted to Cavell Hospital and who were risk
assessed for venous thromboembolisation during the reporting period
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
100%
Apr 13 – Jan 14
96
100
79
This result was achieved through monthly audits of VTE risk assessments and a
continued and ongoing focus on the importance of carrying out VTE risk assessments for
all patients.
8.6
The rate per 100,000 bed days of cases of C Difficile infection reported within the Cavell
Hospital amongst patients aged 2 and over during the reporting period:
Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
0
Apr 12 – Mar 13
17.3
30.8
0
This was achieved, and will be continued to be maintained through strict adherence to
infection prevention and control policies, through working closely with our Link Consultant
Microbiologist and Antibiotic prescribing management.
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8
Mandatory Quality Indicators (continued):-
8.7
The number and rate of patient safety incidents reported within the Cavell Hospital during
the reporting period:i) Number of Patient Safety Incidents reported:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
10.83
Apr 12 – Mar 13
44.55
1,810
0
ii) Rate of Patient Safety Incidents reported:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
3.998
Apr 12 – Mar 13
7.76
30.95
1.68
iii) Number of Patient Safety Incidents that resulted in severe harm or death:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
0
Apr 12 – Mar 13
0.64
28
0
iv) Percentage of Patient Safety Incidents that resulted in severe harm or death:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
0%
Apr 12 – Mar 13
0.9
2.9
0.0
These figures are well below national average. Cavell Hospital has a strong reporting
culture, all of which are discussed at monthly clinical meetings and quarterly Risk &
Governance Committee meetings, and appropriate actions taken as necessary. All
incidents and any learns from incidents are shared with all the clinical teams.
8.8
The percentage of staff employed by Cavell Hospital during the reporting period , who
would recommend the Cavell Hospital as a provider of care to their friends and family:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
%
2013
64.58
96.43
33.73
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ϭϲ
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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 Cavell Hospital as a provider of
care to their family or friends:Unit
Reporting
Periods
National
Average
Highest
National Score
Lowest
National Score
81.45%
Jun 13 – Jan 14
66.23
94.38
35.63
This figure is well above the national average. Cavell intends to focus on this particular
question in the patient feedback forms to increase response rates and thus scores in the
friends and family test. A Patient Satisfaction Focus Group evening is also being held in
June 2014 where patients have been invited to discuss their stay – this should enable
actions to be taken to ensure that the patient’s stay is improved in general which should
lead to an increase in the friends and family score.
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ϭϳ
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