D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
BMI The Garden Hospital Quality Accounts
April 2013 to March 2014
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
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 Today that work has been superseded by the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
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
Ϯ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
represented here and, more importantly, in the experiences of every patient who steps across
our threshold.
Stephen Collier
Chief Executive Officer
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϯ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
Hospital Information
BMI The Garden Hospital is a 29 bed acute general hospital situated in Hendon, London and is
easily accessible, with transport links from central London and surrounding areas. The hospital
offers the privacy and comfort of en-suite facilities, satellite TV and telephone, ten consulting
rooms, two operating theatres, minor ops rooms, outpatient cardiology, physiotherapy and an
onsite pharmacy department. The hospital also has an imaging suite with a 1.5t MRI and Dental
CT scanner.
The Garden Hospital offers choose & book NHS services for diagnostic and orthopaedic,
urology, gynaecology, ophthalmic, endoscopy and general surgery. We have a NHS musicians’
clinic for upper limb surgery and sports injury for 18yrs and above. The Garden Hospital sees in
the region of 15-30% of NHS patients to private patients.
The Physiotherapy department offers a unique Whole Body Cryotherapy service (WBC) which is
the exposure of the entire body to extreme cold (usually between -80 to -120 degrees Celsius).
The Consulting suite has ten consulting rooms, two minor procedure clinics offering Walk-inWalk-out services for Hysteroscopy and Cystoscopy services. One-stop Dermatology/Plastics
shop, One-stop Paediatric outpatients specialities such as Allergy, Paediatric Cardiology,
Hypermobility, Rheumatic Diseases, minor invasive procedures for patients aged 12 and above
and phlebotomy from 3 to 16yrs age.
Outpatient Cardiology service including Cardiac MRI, Electrocardiogram,
Electrocardiogram, Echocardiograms and Paediatric Echocardiograms.
Stress
The Imaging department has a Dental CT scanner, mammography and ultrasound facilities.
NHS patients represented 31.8% of our admissions for the financial year.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϰ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The Garden is registered as a location for the following
regulated services:Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Family Planning
The CQC carried out an unannounced inspection on 29th October 2013 and reported on the
following:
There were two patients admitted to the in-patient ward on the day of our visit and we were able
to speak with one of them. We also spoke with several patients who were attending out-patient
appointments. Everyone told us they were happy with the care and treatment provided. For
example, one patient told us they had been “treated perfectly.” In the out-patient department a
patient told us their treatment had been explained clearly and they felt “comfortable asking
questions.” Patients told us they felt safe using the service and had confidence in the staff.
Everyone said they would recommend the hospital to others. Patients considered the service
was clean and hygienic. For example, one patient described the hospital as “spotless.” There
had been no cases of hospital acquired infection in 2013. There were effective systems in place
to reduce the risk of infection. There was an effective system in place for assessing and
monitoring the quality of the service patients received. Records kept by the service were
accurate and fit for purpose
Care and welfare of people that use services
Safeguarding people who use services from abuse
Cleanliness and Infection Control
Assessing and monitoring the quality of service provision
Records.
The Garden 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 operationalized.
At corporate level the Clinical Governance Board has an overview and provides the strategic
leadership for corporate learning and quality improvement.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϱ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
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
Garden Hospital.
We have had: No cases of MRSA bacteraemia in the last year (NHS
1.17cases/100,000 bed days).
No MSSA bacteraemia cases.
1 E.coli bacteraemia case and 0.01% (1 patient) of hospital apportioned Clostridium Difficile
were reported during the reporting period from April 2013 to March 2014. As reported later in
the report, on investigation, it was found that neither patient acquired the infections at The
Garden Hospital.
SSI data is also collected and submitted to Public Health England for orthopaedic surgical
procedures. Our rates of infection are:
0% Hips
0% Knees
We audit our Infection Prevention within the Garden Hospital by completing monthly audits.
Each month there is a different focus regarding Infection Prevention audits. The audits are
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϲ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
always reviewed and action plans are put in place to improve the Infection Prevention of the
Hospital.
At the present moment we are looking at updating the individual departmental cleaning records
and ensuring that we have regular Infection Prevention meetings, therefore involving the link
nurses within their own specialty to improve our Infection control. We are supported with this by
our linked Microbiologist at the Garden Hospital.
We are proactive with the VIP scoring and are working towards the catheter care bundle. We
are at present trialing a bladder scanner which will enhance the clinical decision on patients that
are in retention post operatively; therefore ensuring that our patients are given evidenced-based
care.
Due to our robust pre-assessment pathway we are able to screen and manage any clinical
complications prior to the patients being admitted. We have a pathway to ensure all MRSA
patients are treated prior to the admission to hospital.
We are proactive with our hand hygiene training and hold a hand washing day once a year,
along with the National Day. We strive to train all our staff with the Infection Prevention training
through BMI. This has both practical and theoretical components.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
The graph below shows our room cleanliness.
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
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϳ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
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 a patient’s privacy and dignity, food, cleanliness and general building maintenance. It
focuses entirely on the care environment and does not cover clinical care provision or how well
staff members are doing their job.
The Garden Hospital has recently had a change of Director of Clinical Services, and although
delayed, the PLACE audit will be completed within the required time frame.
1.3 Venous Thrombo-embolism (VTE)
BMI Healthcare holds VTE Exemplar Centre status by the Department of Health across its
whole network of hospitals including The Garden. BMI Healthcare was awarded the Best VTE
Education Initiative Award category by Lifeblood in February 2013 and was the Runner-up in the
Best VTE Patient Information category.
We see this as an important initiative to further assure patient safety and care. We audit our
compliance with our requirement to VTE risk assess every patient and the results of our audit on
this has shown that the continued usage of these risk assessments, patient information leaflets,
prophylaxis protocols, training and continuous audit, demonstrates full and ongoing compliance,
therefore minimizing the risks to our patients. The Garden Hospital VTE results show 100%
compliance and we are happy to report that we have had no patients with reported VTEs that
we are aware of.
VTE is a standing agenda item on our bi-monthly Medicines Management Committee.
The Garden 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. The
outcomes of these are measured through monthly audit, non-compliance addressed at
Integrated Governance Board and MAC meetings.
2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Although information pertaining to The Garden Hospital is unavailable from PROMs for this
reporting period, all patients, including those referred from the NHS, are actively encouraged to
complete and return the Quality Health questionnaire. The Garden Hospital values the opinion
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϴ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
of all patients and strives to continually improve our quality of care, whilst respecting the
opinions of our customers whether they are referred privately or from the NHS.
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.
Currently this programme is only for Total Hip and Knee surgery, this applies to both NHS and
private patients.
At the Garden Hospital the Enhanced Recovery programme has been implemented for about a
year now.
The Hospital and the Pre-assessment team work closely with Vitaflo who provide the preloading drinks and full explanation and instructions given by pre assessment staff.
Initially two Orthopaedic Consultants were encouraged to use the pre-loading product for their
patients. It was offered to these patients at the Pre-Operative Assessment Clinic.
We immediately noticed that patients were quicker to recover – particularly the day cases –
there was a significant reduction in post-operative nausea and vomiting. The Physiotherapy
department noticed that patients were quicker to get up and therefore the patients were quicker
to be discharged.
The staff in the Recovery unit also noticed that the nausea and vomiting was reduced. So
therefore patients spent less time in recovery and were sent back to their rooms quicker.
A request was put through to the MAC that all patients be considered with the carb loading.
Consultants were approached and evidence was sent to them along with an information pack.
We now pre load 95% of our patients with great success. The uptake has mainly been
orthopaedic and gynaecology.
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.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϵ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
Due to the trend of unplanned re admissions we have reviewed our reporting practice and it has
become apparent that we were over reporting. This has now been reported through the Clinical
Governance Board and correct reporting practices have been cascaded to staff. We are pleased
to report that we have had no unplanned returns to theatre.
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.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϬ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϭ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
The Garden 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.
The table below shows the complaints in the quarter of January to March 2014.
The table summarizes all complaints by type and department.
A total of 11 complaints have been received, this represents 1.57% of all inpatient admissions
during this quarter.
All of the complaints have been responded to within the Complaints Policy timescale.
Note: Some of the complaints are related to several areas and departments.
Customer
Care
Finance
Consultant
Ward
Radiology
Catering
Oncology
Reception
Housekeeping
Appointments
Physiotherapy
Outpatients
Admissions
Theatres
Car Park
Environment
Patient
Administration
Patient
Care
Clinical
Outcome
8
1
1
1
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
1
ϭϮ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
4. CQUINS
The Garden Hospital took part in CQUINs for North and East London (NEL), and East of
England (EoE).
NCL:
VTE risk assessments
Friends and Family
Smoking cessation
Nutritional Risk Assessments
Catheter care bundles
EofE:
VTE risk assessment
Friends and Family
Safety thermometer
Catheter care bundles
Post discharge Phone calls
Lifestyle changes.
All of these were monitored and for both CQUINs, The Garden Hospital was either mostly or
fully compliant
5. National Clinical Audits
The Garden 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.
7. Priorities for service development and Improvement
•
•
•
•
•
The continuous refurbishment of patient rooms.
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 through audit of infection rates.
Further develop and enhance availability of performance and quality indicators for
patients, consultants, referrers and commissioners.
Extension of collection of PROMS to include hip and knee replacement for all patients.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϯ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
Improve and maintain our patient satisfaction scores with admission, pain control and
discharge process.
•
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Garden Hospital for the reporting period.
Unit
Value
and
Banding
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 Garden considers that this data is as described as we predominantly take day cases and
we pre-assess all our patients. All patients are pre-assessed and no ASA score is taken above
2.
8.2 Due to low numbers of patients attending for the following surgeries at The Garden Hospital,
we do not have patient reported outcome measures scores for:
Varicose vein surgery
Hip replacement surgery
Knee replacement surgery
However, as discussed earlier in this report, we have a robust Pre-Assessment and ERP
programme in place which benefits the patient by improving their recovery pathway.
8.3(i) The Garden Hospital does not admit children under the age of 16, therefore we had no readmissions for any child under the age of 15.
8.3(ii) 6 patients aged 15 or over were readmitted to The Garden Hospital within 28 days of
being discharged from April 2013 to March 2014.
Unit
6
Reporting Periods
(at least last two
reporting periods)
Apr11-Mar12
National
Average
Highest National
Score
Lowest National
Score
10.01
14.51
5.54
Following investigation, it was found that there was no trend connecting these incidents and the
factors for re-admission were in general due to potential risks associated with surgery
performed.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϰ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
8.4 The responsiveness of The Garden Hospital to the personal needs of its patients during the
reporting period was 88.2%, well above the National average.
Unit
88.2%
Reporting Periods
(at least last two
reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
Although the score is above the national average, The Garden Hospital will aim to continuously
improve this score to at least match the BMI score of 92.17%.
8.5 We are pleased to report that 100% of patients who were admitted to The Garden Hospital
from April 2013 to March 2014 were risk assessed for venous thrombo-embolism during the
reporting period.
Unit
100%
Reporting Periods
(at least last two
reporting periods)
Apr13 –Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
The importance of VTE assessment is discussed at ward meetings and corporate VTE audits
are in place. A corporate audit tool is used to monitor VTE activity quarterly. Our Pharmacy
team liaises with appropriate Consultants regarding correct prescription of VTE prophylaxis.
Going forward in 2014, any pharmaceutical updates will be distributed to relevant departments
along with sign off sheets which staff members must read and sign to ensure that they are kept
up to date with any changes. VTE is an agenda item at the Medicines Management Committee
meetings on site.
8.6 Although there was one episode of C Difficile reported at The Garden Hospital from April
2013 to March 2014, it was subsequently reported that the infection had not been acquired at
our hospital, it was a pre-existing condition.
Unit
0.11%Rate
Reporting Periods
(at least last two
reporting periods)
Apr 12-13
National
Average
Highest National
Score
Lowest National
Score
17.3
30.3
0
The Garden Hospital has raised and discussed the issue of inaccurate reporting at the hospital’s
Integrated Governance Board. Going forward, the Hospital Administrator responsible for
inputting incident information on to the data base is now attending departmental meetings on
site to reiterate correct reporting and the importance of doing so.
8.7 There were 53 adverse clinical incidents reported at The Garden Hospital from April 2013 to
March 2014, this was an average monthly rate of 2.23. There were 11 Non Adverse clinical
incidents also during this period, which produced an average monthly rate of 0.43. Reporting
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϱ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
non adverse as well as adverse incidents shows that the reporting of such is an important and
necessary process at The Garden Hospital, which ultimately reduces potential risks.
The number of patient safety incidents reported at The Garden Hospital was slightly greater
than the national average.
Unit
53
Reporting Periods
(at least last two
reporting periods)
Apr 12-13
National
Average
Highest National
Score
Lowest National
Score
44.55
1,810
0
The rate of patient safety incidents reported at The Garden was significantly below the national
average.
Unit
2.23
Reporting Periods
(at least last two
reporting periods)
Apr 12-13
National
Average
Highest National
Score
Lowest National
Score
7.76
30.95
1.68
We are happy to report that we had no patient safety incidents that resulted in severe harm or
death
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12-13
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)
2013
National
Average
Highest National
Score
Lowest National
Score
0.9
2.9
0.0
The importance of an open, no blame culture in relation to incident reporting is important at The
Garden Hospital. Staff members are reminded at departmental meetings and via staff forum to
report any incidents, including near misses to their Heads of Department and on Sentinel.
8.8 The percentage of staff employed by The Garden Hospital during the reporting period, who
would recommend us as a provider of care to their family or friends.
Unit
72%
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϲ
D/,ĞĂůƚŚĐĂƌĞ^ĞƌŝŽƵƐĂďŽƵƚŚĞĂůƚŚ͘WĂƐƐŝŽŶĂƚĞĂďŽƵƚĐĂƌĞ͘
9. Non-Mandatory Quality Indicators
9.1 77% of patients, who received care as inpatients from June 2013 to January 2014, would
recommend The Garden Hospital as a provider of care to their family or friends.
Unit
77%
Reporting Periods
(at least last two
reporting periods)
June 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63
Although greater than the national average, we aim to improve this score moving forward.
Lower scores were allocated to accommodation and catering in most cases. An on-going
redecoration programme is in place and again we are continually aiming to improve our scores.
D/dŚĞ'ĂƌĚĞŶ,ŽƐƉŝƚĂůYƵĂůŝƚLJĐĐŽƵŶƚƐϮϬϭϯͲϮϬϭϰ
ϭϳ