BMI HUDDERSFIELD HOSPITAL
QUALITY ACCOUNT 2013/14
1
BMI Huddersfield Hospital Quality Accounts
April 2013 to March 2014
Chief Executive’s Statement
Welcome to our Quality Accounts 2014, the fifth year we have
published this data. The information presented here on a broad range
of quality measures continues to grow in importance and usefulness for
patients and commissioners. Quality accounts already provide a key
metric for people to assess the strength of our 66 hospitals and clinics
against other facilities - NHS and independent - from which they might
receive their care.
For BMI Healthcare and every other private provider the importance of
comparable quality data was recently reinforced by the conclusions of
the Competition Commission’s market investigation into private
healthcare. From the outset of the inquiry BMI Healthcare supported the
principle that competition in the sector would be enhanced if private
hospitals produced comparable quality data, and that competition
amongst hospitals would drive up service standards. We were therefore
fully supportive when the Commission announced in April that it is
mandating the provision of greater information on the performance of hospital operators and consultants.
We wholeheartedly agree when the Commission says that “a more transparent market with patients
actively making choices will drive hospital operators to compete on the things that matter to patients”.
Whilst we are yet to see how the Commission will ensure that this is enacted, the private sector
continues to take its own steps. Five years ago BMI Healthcare was at the forefront of the sector’s efforts
to be more open about sharing comparable quality and pricing data when we sponsored the launch of
the Hellenic Project. Today that work has been superseded by the Private Hospitals Information Network
which is working towards publishing data that will allow patients and commissioners to make informed
choices - a challenge that the sector must now rise to. We at BMI Healthcare will continue to play our
part in these important developments, which we believe can have a significant role in driving higher
quality standards.
I remain proud, but certainly not complacent, about the quality of care our hospitals provide. Last year
BMI Healthcare invested £40m in our hospitals, supporting our committed staff and consultants to meet
the challenge of providing consistently safe, high quality care. We constantly measure our patients’
experience, and I am pleased to note that in the three months to the end of March 2014, 97.3% of
patients independently surveyed expressed satisfaction with their care and 97.9% said they would
recommend us to others. There is however always room for improvement, and publication of comparable
quality data across the independent sector can only help.
The information available in these quality accounts has been reviewed by the Clinical Governance Board
and I declare that as far as I am aware the information contained in these reports is accurate. I thank all
the staff whose energy and devotion to improvement is represented here and, more importantly, in the
experiences of every patient who steps across our threshold.
Stephen Collier, Chief Executive Officer
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Hospital Information
BMI The Huddersfield Hospital has 29 beds with all rooms offering the privacy and comfort of en-suite
facilities, TV and telephone. The hospital has two theatres which, combined with the latest in technology
and on-site support services, enable 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 a Resident Medical Officer on duty 24 hours a day,
providing care within a friendly and comfortable environment.
BMI Huddersfield Hospital offers the following specialties and services:
Acupuncture
Allergy testing
Anaesthetics
Breast surgery
Cardiology
Chest medicine
Colorectal surgery
Colposcopy
Cosmetic surgery
Dermatology
Endocrinology
Endoscopy
ENT surgery
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Imaging
- Mammography
- MRI scanning
- Ultrasound
- Xray
Neurology
Ophthalmology
Optometry
Oral/maxillofacial surgery
Orthopaedic surgery
Physiotherapy
Plastic and reconstructive surgery
Erectile dysfunction
Family Planning
Gastroenterology
General medicine
General surgery
Geriatric medicine
Gynaecology
Pre-admission clinic
Psychiatry
Radiology
Respiratory medicine
Rheumatology
Sports injury clinic
Urology
Vascular surgery
Patients can access a wide range of services at BMI Huddersfield Hospital through the NHS choose and
book scheme. Between April 2013 – March2014, the hospital cared for 2078 NHS Patients which made
up 71% of the total number of patients treated here during the 12 month period.
BMI Huddersfield Hospital continues our commitment to improving the services offered to patients to
ensure the highest possible quality of care is being delivered.
The staff at the BMI Huddersfield Hospital are driven to provide excellent standards of customer service.
This is reflected in the patient satisfaction survey results that show a consistent 95-100% of patients are
satisfied with the quality of care provided.
4
In 2013-14 work has been completed to replace the old roof along with the installation of improved
insulation in the roof cavity and secondary glazing to windows that will provide improved insulation,
resulting in optimized temperature control in patient areas.
There is an ongoing commitment to ensure that theatre equipment is being replaced when required to
ensure that Consultants have the most up to date and reliable equipment available to them.
The most significant recent purchases are new state of the art anaesthetic machines along with patient
monitors and orthopaedic drills. There was also a capital investment to purchase a new ultrasound
machine in the imaging department.
The reception area in the hospital has recently been refurbished and reception area toilets have been
upgraded.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the Health &
Social Care Act 2008. BMI Huddersfield Hospital is registered as a location for the following regulated
services:-
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•
Treatment of disease, disorder and injury
•
Surgical procedures
•
Diagnostic and screening
•
Family planning
The CQC carried out an unannounced inspection on 10th December 2013 and found compliance with the
following standards:
BMI Huddersfield Hospital has a local framework through which clinical effectiveness, clinical incidents
and clinical quality is monitored and analysed. Where appropriate, action is taken to continuously
improve the quality of care. This is through the work of a multidisciplinary group and the Medical
Advisory Committee.
The Regional Clinical Quality Assurance Board monitors and analyses trends and ensure that quality
improvements are operationalised.
At corporate level the Clinical Governance Board maintains an overview and provides strategic
leadership and direction 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.
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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 at Huddersfield Hospital.
Systems are in place to actively monitor the incidence of
healthcare associated infections in-particular alert organisms
such as MRSA, Clostridium difficile infections and postoperative surgical site infections. All infections suspected or
confirmed are investigated thoroughly and if confirmed they are
reported via the Clinical Governance framework.
Rates of infection at BMI Huddersfield are as follows:
IPC Alert
Source
Rate
Bacteraemia
0
Hospital Acquired Infection
0
MRSA
Hospital Acquired Colonisation 0
Community Acquired
Hosp. Acquired
0
0
Hosp. Acquired
0
Community Acquired
Hosp. Acquired
0
0
Community Acquired
0
CDI
E-coli Bacteraemia
MSSA Bacteraemias
7
IPC Alert
SSI
Source
Rate
Superficial/stitch abscess
2
Deep incisional
1
Deep/organ space Infection
0
Outbreaks
0
Catheter Associated
UTI
Hospital Acquired
0
In October 2013 BMI Huddersfield voluntarily joined the Public Health England (PHE) Surgical Site
Infection Surveillance System, actively collecting data on all patients receiving hip and knee
replacements and submitting data including rates of infection to the PHE data-base. 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 BMI Huddersfield and the NHS as a whole.
In summary:
Surgery
Quarter
Total
No
No
of
SSI
No
of
SSI
as %
Hip
Oct –
Replacement Dec
2013
Jan-Mar
2014
17
0
0%
Knee
Oct-Dec
Replacement 2013
Jan-Mar
2014
41
o
0%
0%
Cumulative
ALL
Rate of
Hospitals
Infection % Cumulative
Rate of
Infection %
0%
1.2%
Data not
yet
published
0%
1.7%
Data not
yet
published
As per DH recommendations BMI Huddersfield Hospital has appointed a Director of Infection Prevention
and Control (DIPC) at each Hospital site, who is supported by a Consultant Microbiologist, Infection
Prevention Nurse (IPN) and link workers to facilitate ‘board to ward’ buy in for IPC. The site Infection
Prevention team meets quarterly to discuss all matters relating to IPC including water safety,
decontamination, infection issues and Root Cause Analyses (RCA) and surveillance.
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 September
2013 the IPN team introduced Aseptic Non-Touch Technique (ANTT) training for all staff who undertake
8
some form of clinical intervention as part of their role; this training has 2 elements – a theory and a
practical assessment, both of which require annual updates.
In December 2013 training was provided to key clinical staff on the implementation of the DH care
bundles/high impact interventions. Bundles for Cannula insertion and on-going care as well as urethral
catheter insertion and on-going care have been implemented and monthly audits completed.
This practice of audit has allowed areas for improvement to be highlighted. High impact intervention
audits will be added to the 2014/15 CQUIN measures.
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 the new system for assessing the quality of the patient
environment, replacing the old Patient Environment Action Team (PEAT) inspections.
The assessments involve patients and staff who assess the hospital and how the environment supports
patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on
the care environment and does not cover clinical care provision or how well staff are doing their job.
9
The results are shown in the table below:
This is the first year PLACE has taken place at BMI Huddersfield Hospital, therefore there are no
previous results to compare with. These results will set the benchmark for improvement in 2014. The
infection control team are working with the hospital teams towards achieving improved results for the
2014 assessment that will be carried out in May.
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 Huddersfield 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 we have been consistently achieving a 96-100% compliance rate.
The hospital now has a dedicated VTE link nurse who is working closely with consultants to ensure that
hospital policies and procedures are in line with current best practice guidelines and a clear process is
followed to ensure all patients are appropriately risk assessed prior to theatre.
VTE Risk Assessment (N3.1)
% of all* adult inpatients who have had a VTE risk
Description of
assessment on admission to hospital using the
Indicator
clinical criteria of the national tool
Number of adults* who were admitted as
inpatients (includes day cases, maternity and
Denominator
transfers; both elective and non-elective
admissions)
Number of adult inpatient admissions reported as
having had a VTE risk assessment on admission
Numerator
to hospital using the clinical criteria of the national
tool
Percentage of adult inpatient admissions
reported as having had a VTE risk assessment on
Performance
admission to hospital using the clinical criteria of
the national tool (Numerator / Denominater x 100)
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BMI Huddersfield Hospital reports the incidence of Venous Thromboembolism (VTE) through the
corporate clinical incident system. It is acknowledged that the challenge is receiving information for
10
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. .
BMI Huddersfield Hospital had 5 incidents of confirmed DVT and 2 incidents of confirmed pulmonary
embolism between April 2013- March 2014. This is an increase from the previous year but is reflective of
the increase in the complexity of patient care that has been undertaken with a significant increase in t of
orthopaedic surgery. Despite a rise in incidents we continue to have very low rate of confirmed VTE per
100 patients. There has been a significant improvement in the reporting of VTE in the last 12 months
following a project of work encouraging patients to contact BMI Huddersfield Hospital with any postoperative concerns.
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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.
Latest results can be found by going on the online SOLAR system provided to you by Quality Health
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 The BMI Huddersfield Hospital. The results for both hip and knee
PROMS are higher than the national average and for knees the results are significantly higher. The
consistently high results are a result of excellent patient experience and our team approach to care from
the initial consultant appointment to consultant delivered surgery through to physiotherapist led
discharge.
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Oxford Hip Score average
April 12 –
Mar 13
Q1
Q2
Health gain between reporting
periods
22.364
41.909
19.545
Huddersfield
17.907 39.224
21.317
England
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All
rights reserved.'
Oxford Knee Score average
April 12 –
Mar 13
Q1
Q2
Health gain between reporting
periods
23.71
40.032
16.323
Huddersfield
18.893 34.902
16.01
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.
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 co-morbidities,
medication assessment – stopping medication plan.
d. Commencement of discharge planning
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3. Proactive patient management
a. Maintaining good pre-operative hydration
b. Minimising the risk of post-operative nausea and vomiting
c. Maintaining normothermia pre and post operatively
d. Early mobilisation
4. Encouraging patients have an active role in their recovery
a. Participate in the decision making process prior to surgery
b. Education of patient and family
c. Setting own goals daily
d. Participate in their discharge planning
BMI Huddersfield Hospital has a multidisciplinary team of professionals who deliver a successful ERP
pathway of care to patients. There is a dedicated Pre Assessment team who manage patient expectation
regarding length of stay and commence the discharge process before patients are admitted, ensuring all
their home care needs are met and any intervention required post discharge is pre- planned. We have a
team of physiotherapists who work closely with the Consultants to promote early and continued
mobilisation of patients post operatively. Our current statistics show our average length of stay, year to
date for knee replacements is 3.1 days and for hip replacements 2.8 days.
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. At BMI Huddersfield there have been very few returns to theatre or re
admissions within 31 days and the data shows a reduction in both cases over the last 12 months.
14
15
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.
At BMI Huddersfield hospital we try to involve our patients with all aspects of their care and treatment.
This is reflected in the results below with 100% of patients feeling satisfied that they were involved in the
decisions that were made about their care:
We encourage our staff to talk to patients about their concerns and 95-100% of patients responded
positively to thi squestion:
16
We have seen a slight increase in the already high scores of patients who would recommend us
following care they have received at the hospital:
All of our patients are treated with dignity and respect and this is reflected in the survey results with
100% of patients confirming they were treated with dignity and respect during their stay
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Huddersfield Hospital actively encourages feedback both informally and formally. Patients are supported
through a robust complaints procedure, operated over three stages:
17
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 data above shows that BMI Huddersfield Hospital experienced an increase in the number of written
complaints. Although the data demonstrates that significantly less than one percent of admitted patients
complain we do take all complaints seriously and treat each as an individual learning opportunity. The
majority of complaints can be categorised into two trends. One administrative errors and the other
nursing care. Our administration team is now fully recruited to and a robust training induction and training
package is in place to ensure consistent adherence to the administrative processes. We have
rearranged the ward managers role so her only area of responsibility is ward. This will provide time to
concentrate on our patients and their immediate needs as well as training and development for the
nursing team.
There is a very clearly defined complaints procedure which ensures complaints are dealt with promptly
and professionally. The hospital Executive Director personally responds to every customer who has a
complaint.
The hospital has a structured lessons learned process whereby the outcomes of complaints are
communicated to staff to ensure correct policy and procedures are being followed at all times.
18
4. CQUINS
The key aim of the Commissioning for Quality and Innovation (CQUIN) framework for 2013/14 was to
secure improvements in quality of services and better outcomes for patients.
In 2013/14 the friends and family test was added to the national CQUIN framework and was integrated
into the BMI Huddersfield Hospital CQUIN targets.
BMI Huddersfield Hospital work closely with the local Care Commissioning Group(CCG) to agree local
targets that reflect the local patient demographic. Regular meetings are held with the CCG to monitor
progress of agreed targets. This year’s local CQUIN measures included implementation of 48 hour post
discharge call for day case patients and brief intervention for those patients identified as drinking more
than the recommended weekly consumption of alcohol.
The tables below give a summary of the CQUIN data for BMI Huddersfield Hospital during 2013/14. The
first table gives a summary of the goals for the 2013/14 CQUINS followed by the results the hospital
achieved.
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1.1
FFT Implementation: achieving full implementation / phased
expansion in line with national milestones (Y/N)
Yes
1.2
FFT Response Rate - 20% by Q4 (current response rate)
9.90% 19.30% 12.20% 13.80%
1.3
FFT Implementation of question in staff survey by Q4
Yes
Yes
Yes
N/A
NHS Safety Thermometer (N2)
Yes
Yes
Yes
Yes
Yes
VTE Risk Assessment (N3.1)
Yes
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Yes
Yes
Yes
6.67% 28.90% 21.80% 19.12%
Yes
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Safety Thermometer survey data for all approriate patients, in
all appropriate settings for relevant measures submitted (to
NHS Information Centre by BMI IMU)?
Yes
6.80% 58.40% 39.70% 34.97% 22.30% 32.70% 33.90% 29.63%
N/A
N/A
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Requires monthly surveying all appropriate patients to collect
data on pressure ulcers, falls, UTI in patients with catheters
Description of
and VTE. A completed Safety Thermometer survey for all
Indicator
relevant patients must be included for each month in the
relevant quarter’s submission to trigger payment.
% of all* adult inpatients who have had a VTE risk
Description of
assessment on admission to hospital using the
Indicator
clinical criteria of the national tool
Number of adults* who were admitted as
inpatients (includes day cases, maternity and
Denominator
transfers; both elective and non-elective
admissions)
Number of adult inpatient admissions reported as
having had a VTE risk assessment on admission
Numerator
to hospital using the clinical criteria of the national
tool
Percentage of adult inpatient admissions
reported as having had a VTE risk assessment on
Performance
admission to hospital using the clinical criteria of
the national tool (Numerator / Denominater x 100)
Yes
ĂƚĂĨŽƌ
ĞǀĞƌLJ
ŵŽŶƚŚ
ŝŶYϯ͍ :ĂŶͲϭϰ &ĞďͲϭϰ DĂƌͲϭϰ
Yes
Yes
Yes
Yes
YƵĂƌƚĞƌϯ
Yes
ĂƚĂĨŽƌ
ĞǀĞƌLJ
ŵŽŶƚŚ
ŝŶYϰ͍
Yes
YƵĂƌƚĞƌϰ
Target
ƉƌͲϭϯ DĂLJͲϭϯ :ƵŶͲϭϯ
Yϭ
:ƵůͲϭϯ ƵŐͲϭϯ ^ĞƉͲϭϯ
YϮ
KĐƚͲϭϯ EŽǀͲϭϯ ĞĐͲϭϯ
Yϯ
:ĂŶͲϭϰ &ĞďͲϭϰ DĂƌͲϭϰ
Yϰ
Ϯϭϵ
ϮϮϴ
ϭϵϵ
ϲϰϲ
ϮϬϮ
ϭϲϵ
Ϯϭϭ
ϱϴϮ
ϭϵϬ
ϮϬϱ
ϭϭϬ
ϱϬϱ
ϮϬϮ
ϭϵϴ
ϭϵϭ
ϱϵϭ
Ϯϭϵ
ϮϮϭ
ϭϵϵ
ϲϯϵ
ϮϬϮ
ϭϲϵ
ϭϵϰ
ϱϲϱ
ϭϴϳ
ϮϬϭ
ϭϬϳ
ϰϵϱ
ϭϵϴ
ϭϵϬ
ϭϴϰ
ϱϳϮ
ϵϴ͘ϵй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй
ϵϮ͘ϭй
ϵϳ͘ϭй
ϵϴ͘ϰй
ϵϴ͘Ϭй
ϵϳ͘ϯй
ϵϴ͘Ϭй
ϵϴ͘Ϭй
ϵϲ͘Ϭй
ϵϲ͘ϯй
ϵϲ͘ϴй
95%
ϭϬϬ͘Ϭй
ϵϲ͘ϵй ϭϬϬ͘Ϭй
NB: *applies to all NHS Standard Acute Contract (SAC) Patients - all PCTs
VTE Route Cause Analysis (N3.2)
Description of % of root cause analyses carried out on cases of
hospital associated thrombosis
Indicator
Number of adult inpatients reported as having had
Denominator
a VTE
Number of adult inpatients reported as having had
Numerator
a VTE where there was a subsequent Route
Cause Analysis
Percentage of cases of hospital associated
Performance thrombosis where a root cause analysis has been
carried out
YƵĂƌƚĞƌϭ
Target
Contact with Day Case Patients (L4)
Description of Contact with all day case surgery patients within 48 hours
post surgery to improve outcomes, reduce complications and
Indicator
re-admissions
Quarterly Requirement Delivered?
YƵĂƌƚĞƌϮ
ƉƌͲϭϯ DĂLJͲϭϯ :ƵŶͲϭϯ
Yϭ
YƵĂƌƚĞƌϯ
:ƵůͲϭϯ ƵŐͲϭϯ ^ĞƉͲϭϯ
a) Number of patients who attend for day-case surgery who
consent to being contacted 48 hours post surgery
Numerator
Number of (a) who are contacted 48 hours post surgery
Performance
Percentage of day-case patients who consent to contact
that are contacted within 48 hours post surgery
Well-Being - Alcohol (L5)
Development and implementation of action plan to ensure that
Description of levels of alcohol consumption are recorded for admitted
patients and, where appropriate, patients are given brief advice
Indicator
and/or sign-posted/referred to appropriate services
Quarterly Requirement Delivered?
Percentage of a) Patients appropriate for advice / referral
where this is given / completed (b)
20
Yϯ
:ĂŶͲϭϰ &ĞďͲϭϰ DĂƌͲϭϰ
Yϰ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
ϭ
Ϭ
Ϭ
ϭ
Ϭ
Ϭ
ϭ
ϭ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
Ϭ
ϭ
Ϭ
Ϭ
ϭ
Ϭ
Ϭ
ϭ
ϭ
ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй ϭϬϬ͘Ϭй
YƵĂƌƚĞƌϭ
YƵĂƌƚĞƌϮ
WƌŽǀŝƐŝŽŶŽĨĐƚŝŽŶΘ
/ŵƉůĞŵĞŶƚĂƚŝŽŶWůĂŶ
WƌŽŐƌĞƐƐZĞƉŽƌƚŽŶ
/ŵƉůĞŵĞŶƚĂƚŝŽŶ
zĞƐ
zĞƐ
N/A
Eͬ
YƵĂƌƚĞƌϯ
WƌŽŐƌĞƐƐZĞƉŽƌƚŽŶ
/ŵƉůĞŵĞŶƚĂƚŝŽŶΘ
ĂƐĞůŝŶĞĂƚĂƚŽ^ĞƚYϰdƌĂũĞĐƚŽƌLJ
YƵĂƌƚĞƌϰ
ĐŚŝĞǀĞŵĞŶƚŽĨŐƌĞĞĚ
dƌĂũĞĐƚŽƌLJ
zĞƐ
zĞƐ
ϯϴϴ
Ϯϳϲ
ϯϳϳ
Ϯϳϲ
Ϯϭϱ
ϭϴϮ
ϱϳ͘Ϭϯй
ϲϱ͘ϵй
YƵĂƌƚĞƌϭ
YƵĂƌƚĞƌϮ
YƵĂƌƚĞƌϯ
YƵĂƌƚĞƌϰ
WƌŽǀŝƐŝŽŶŽĨĐƚŝŽŶWůĂŶĨŽƌ
/ŵƉůĞŵĞŶƚĂƚŝŽŶ
WƌŽŐƌĞƐƐZĞƉŽƌƚŽŶ
/ŵƉůĞŵĞŶƚĂƚŝŽŶ
WƌŽŐƌĞƐƐZĞƉŽƌƚŽŶ
/ŵƉůĞŵĞŶƚĂƚŝŽŶ
ǀŝĚĞŶĐĞŽĨ&Ƶůů/ŵƉůĞŵĞŶƚĂƚŝŽŶ
ΘŽůůĞĐƚŝŽŶŽĨĂƚĂƐĞƚ
zĞƐ
zĞƐ
zĞƐ
zĞƐ
N/A
Eͬ
Eͬ
a) Total number of admitted patients identified as appropriate
for advice / referral
b) Total number of a) given brief advice and/or referred to
appropriate service
YƵĂƌƚĞƌϰ
KĐƚͲϭϯ EŽǀͲϭϯ ĞĐͲϭϯ
Ϭ
Total number of patients attending for day-case surgery
Denominator
YϮ
Ϯϳ
Ϯϱ
ϵϮ͘ϱϵй
5. National Clinical Audits
BMI Huddersfield Hospital was only eligible to participate in National Joint Registry audit and all joint
replacements are submitted to this. The hospital shows good compliance with data input into the register
with 100% of eligible patients giving consent for their data to be used in the register and 100% link-ability
to the patients NHS number.
Looking forward to the next 12 months the BMI Huddersfield Hospital will continually strive to to achieve
100% on the above areas together with further key aims to ensure continued compliance with data input
into the National joint Registry;
•
To provide high quality and relevant data in line with the National Joint Registry’s mission
statement
•
To set up Key Performance Indicators in line with the key quality indicators of Compliance,
Consent and Link-ability.
•
To respond to National Joint Registry’s requested information within the agreed timescales.
•
To improve performance in the key quality indicators in line with National averages
6.Research
No NHS patients were recruited to take part in research.
7.Priorities for service development and improvement
Following an initial review of the priorities for service development, over the last 12 months the BMI
Huddersfield Hospital now has ongoing improvement, development and engagement with the Clinical
Governance process and reporting tools at hospital and corporate level, capital investment has been
made in equipment and instrument replacement, environmental and safety improvements have been
made in clinical areas. These include: Operating Theatre improvements, patient bedroom
upgrade/refurbishment, Main Reception refurbishment. There has also been an ongoing drive to improve
patient satisfaction which includes the introduction of customer care training (mandatory for all staff) and
the development of a patient satisfaction group to action and champion staff ideas to generate an
improvement in patient satisfaction results.
With patient safety being paramount in all new developments the hospital undertakes, the hospital
management team have taken a strategic approach to plan the delivery of the following objectives over
the next 12 months;
•
21
Redevelopment of the pre-operative assessment clinical pathway and end to end process for
booking patients into theatre which will reduce cancellations and ensure an efficient and hassle
free service for patients and Consultants.
•
Improvements to the way in which Safety, Health and the Environment (SHE) issues are reported
through the implementation of sub groups and a wider understanding and implementation of
audit.
•
A robust internal audit action plan and subsequent implementation of information security
development will be implemented
•
There will be a realignment of patient services to provide a more responsive service for our
patients.
8. Mandatory Quality Indicators
8.1 The BMI Huddersfield Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.109
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 BMI Huddersfield Hospital considers that this data is as described for the following reasons:
This is a comparable score with the National Average but could be improved by reviewing the post
discharge pathway with input from the physiotherapy team.
(ii) Hip replacement surgery
Unit
22.504
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 BMI Huddersfield Hospital considers that this data is as described for the following reasons:
With an above national average score the enhanced recovery programme at the hospital is contributing
to good patient outcomes, this programme will continue to be developed further.
(iii) Knee replacement surgery during the reporting period.
Unit
18.906
22
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 BMI Huddersfield Hospital considers that this data is as described for the following reason:
With an above national average score the enhanced recovery programme at the hospital is contributing
to good patient outcomes, this programme will continue to be developed further.
8.3 The percentage of patients aged 15 or over readmitted to a hospital which forms part of the BMI
Huddersfield Hospital within 28 days of being discharged from a hospital which forms part of the hospital
during the reporting period.
Unit
0.172 %
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 BMI Huddersfield Hospital considers that this data is as described for the following reasons:
Good pre assessment screening and post anaesthetic care results in a low readmission rate.
8.4 The BMI Huddersfield Hospital responsiveness to the personal needs of its patients during the
reporting period.
Unit
91.5 %
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 BMI Huddersfield Hospital considers that this data is as described for the following reasons :
A focus on providing a high standard of customer care to all our patients results in high levels of patient
satisfaction.
8.5 The percentage of patients who were admitted to BMI Huddersfield Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
98%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
The BMI Huddersfield Hospital considers that this data is as described for the following reasons:
A dedicated team of skilled nurses are receive regular training on the prevention of VTE following
surgery and monthly audits are carried out to ensure continued compliance
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the BMI Huddersfield
Hospital amongst patients aged 2 or over during the reporting period.
Unit
23
Reporting Periods
(at least last two
National
Average
Highest National
Score
Lowest National
Score
0
reporting periods)
Apr 12 – Mar 13
17.3
30.8
0
The BMI Huddersfield Hospital considers that this data is as described for the following reasons :
There is a dedicated infection control nurse who delivers regular training throughout the hospital. The
Patient bedrooms and bathrooms are single patients use and hand washing facilities are readily
available with education on hand washing techniques displayed throughout the hospital.
8.7 The number and, where available, rate of patient safety incidents reported within the BMI
Huddersfield 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
95
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
44.55
1,810
0
Rate of patient safety incidents reported (Incidents per 100 Admissions)
Unit
3.272
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
7.76
30.95
1.68
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 (Incidents per 100
Admissions)
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 BMI Huddersfield Hospitals considers that this data is as described for the following reasons:
There is a robust process for the reporting and investigating of incidents. This includes the reporting of
cancellations of surgery and day cases who stay overnight as clinical incidents. There have been no
serious untoward incidents or never events.
8.8 The percentage of staff employed by the BMI Huddersfield Hospital during the reporting period, who
would recommend the BMI Huddersfield Hospital as a provider of care to their family or friends.
24
Unit
68%
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
The BMI Huddersfield Hospital considers that this data is as described for the following reasons:
Although we are scoring above the national average BMI Huddersfield Hospital will be improving
communications with our staff in a variety of ways including staff forums, departmental meetings and
information sharing via email to ensure they are engaged with developments in the hospital.
Non-Mandatory Quality Indicators
9.1 The percentage of patients who received care as inpatients or discharged from A &E during the
reporting period, who would recommend the BMI Huddersfield Hospital as a provider of care to their
family or friends.
Unit
84.9%
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
The BMI Huddersfield Hospital considers that this data is as described for the following reasons:
Although we are scoring above the National average the BMI Huddersfield Hospital will continue to seek
feedback from our patients in a variety of ways to ensure we are listening to concerns and actions are
taken if there are specific areas within the hospital that have a downward trend in patient satisfaction.
25