BMI The Manor 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 Today that work has been superseded by the Private Hospitals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
Hospital Information
BMI The Manor Hospital has 21 beds with all rooms offering
the privacy and comfort of en-suite facilities, free view TV, WiFi and telephone. The hospital has one theatre, endoscopy
department / minor procedure room and another minor
operation room within the Out Patients department.
These facilities combined with the on-site support services
including Imaging / Ultrasound, Physiotherapy and Health
Screening; enable our consultants to undertake a wide range
of procedures from routine investigations to complex surgery.
The 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.
We also run the Choose and Book programme this includes
services such as Orthopedics, General Surgery, Gynecology,
Urology and Gastroenterology. 22% of all our overall referrals
are NHS patients.
This year we replaced our theatre roof and Laminar flow for theatre to improve the facility’s
effectiveness.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The manor Hospital is registered as a location for the following
regulated services:•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
The CQC carried out an unannounced inspection on 10th October 2013 and found that people who
use the service were provided with suitable and sufficient information including preadmission and
discharge packs. People told us the information was very useful. They said they'd received good
explanations about their care and treatment and felt fully informed. They told us they felt well looked
after throughout the course of their care and treatment and this had included undergoing an
assessment process before and on arrival at the service. Our review of their care files confirmed
this. We saw that the explanations provided to people including the risks and benefits involved in
any procedures were well documented. People had received a review of their medical histories and
allergies in all the cases we looked at and were having specific risk factors reviewed and updated
regularly. The people we spoke with said they found staff to be friendly and competent. The staff we
spoke with said they were completing a program of training relevant to their roles and received
appraisals of their competencies and development. The documentation we looked at confirmed this.
We saw that the service appeared clean during our inspection. However, we found that some
infection control processes and practices were lacking. People told us they had no complaints about
the service. We saw the service had a complaints process in place and people's complaints were
responded to appropriately.
Standards of treating people with respect and involving them in their care
Met this standard
Standards of providing care, treatment & support which meets people's needs
Met this standard
Standards of caring for people safely & protecting them from harm
X
Action needed
Standards of staffing
Met this standard
Standards of management
Met this standard
For the above non-compliance, replacements of Gradus impervious floor covering with hard
flooring- risk assessment have now been completed. A robust action plan was put in place. New
replacement flooring in all patient rooms now replaces the carpets. Training was provided to all staff
with further audits and action plans locally completed.
The Manor 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. At corporate level the Clinical Governance Board has an
overview and provides the strategic leadership for corporate learning and quality improvement.
There has been ongoing focus on robust reporting of all incidents, near misses and outcomes. Data
quality has been improved by ongoing training and database improvements. New reporting modules
have increased the speed at which reports are available and the range of fields for analysis. This
ensures the availability of information for effective clinical governance with implementation of
appropriate actions to prevent recurrences in order to improve quality and safety for patients,
visitors and staff.
At present we provide full, standardised information to the NHS, including coding of procedures,
diagnoses and co-morbidities and PROMs for NHS patients. There are additional external reporting
requirements for CQC, Public Health England (Previously HPA) CCGs and Insurers
BMI is a founding member of the Private Healthcare Information Network (PHIN) UK – where we
produce a data set of all patient episodes approaching HES-equivalency and submit this to PHIN for
publication. The data is made available to common standards for inclusion in comparative metrics,
and is published on the PHIN website http://www.phin.org.uk. This website gives patients
information to help them choose or find out more about an independent hospital including the ability
to search by location and procedure.
1. Safety
1.1 Infection prevention and control
The focus on infection prevention and control continues under
the leadership of the Group Head of Infection Prevention and
Control, in liaison with the link nurse in The Manor 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
• Zero cases 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;
o Hips – zero cases
o Knees – zero cases
BMI The Manor Hospital under took the annual infection control audit and achieved an overall score
of 96.5%, an improvement of 2% from last year. Action plans were written and actioned by all
departments from several areas of the audit. No specific trends were noted.
Seven Care Bundles were audited during this period and include Pre-operative, Intra-operative,
Post-Operative, urinal catheterisation, Urinary Catheter on-going care, Peripheral Cannula insertion
and Peripheral Cannula on going care.
10 separate observations were made of nurses and doctors in each area with the hospital achieving
an overall score of 98%. Training focused on hand hygiene, aseptic non touch technique and other
infection prevention activities were also carried out with a compliance of 83%.
Environmental cleanliness is also an important factor in infection prevention and our patients rate
the cleanliness of our facilities highly.
Graph below shows hospital room and bathroom cleanliness scores (% of excellent and very good)
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.
The results will show how hospitals are performing nationally and locally. Overall result of the hospital is
94%.
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 Manor 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 overall average of 95% for the year. Training
provided to all clinical staff and the result of this has been an improvement in result of VTE risk
assessment in the last 4 months of the year; currently at 100%.
The Manor 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. .
2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Patient Reported Outcome Measures (PROMs) are a means of collecting information on the
effectiveness of care delivered to NHS patients as perceived by the patients themselves. PROMs is
a Department of Health led programme.
For the current reporting period, the tables below demonstrate that the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing hip
replacement and knee replacement at The Manor Hospital.
Oxford Hip Score average
April 12 –
Mar 13
The Manor
Hospital
Q1
Q2
Health gain between reporting
periods
20.625
44.875
24.25
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
The Manor
Hospital
Q1
Q2
Health gain between reporting
periods
25
33.444
8.444
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
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
ERP is well embedded at the Manor hospital with all staff fully trained using appropriate clinical
pathways and also we have seen a reduction in average length of stay for our hip and knee
procedures from 5 days to 3.1 days for a Hip operation and 4.4 days to 2.9 days for a knee
operation. Quarterly meetings are held to discuss continuous improvements and keep up
momentum.
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. BMI Manor Hospital has had an on-going decrease in
unplanned returns to theatre and unplanned readmissions over the last 5 years. There have been
no trends of concern identified and monitoring and analysis will continue.
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.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMIThe
Manor 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.
In the reporting period, no complaints escalated to stage two and all were resolved at hospital level.
4. CQUINS
All NHS patients’ notes are audit monthly by Director of Clinical Services to ensure compliance of
VTE risk assessments and safety thermometer. Audited reports are provided to the Clinical
Commissioning group on a quarterly basis. Overall The Manor Hospital has been compliant with
meeting all CQUIN indicators
5. National Clinical Audits
The Manor 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.
7. Priorities for service development and improvement
Based on what our patients tell and all of our monitoring activity the board will be supporting our
focus on the following areas:
•
•
•
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 replacements for NHS patients.
•
Improvements in the management of complaints and responses to patients with roll out of a
corporate toolkit.
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the (The
Manor hospital) for the reporting period.
Unit
0.0000
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 Manor hospital has reported no deaths for the current year.
8.2 The Manor hospital’s patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.059
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 Manor hospital considers that this data is as described for the following reasons; we continue to
provide shorter hospital length of stay and effective pain management, the impact of this has been a
quality service following best practice guidelines and improved outcomes for the patient
(ii) Varicose vein surgery
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
-8.738
8.172
-15.918
National
Average
Highest National
Score
Lowest National
Score
21.280
24.684
17.214
The Manor hospital performed no varicose veins for the year.
(iii) Hip replacement surgery
Unit
24.25
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
The Manor hospital considers that this data is as described and has taken the following actions to
improve the score and the quality of its services, by embedding the enhance recovery programme
with the aim of reducing patients length of stay within the clinical pathways and encouraging them to
have an active role in their recovery through a multi-disciplinary approach.
(iv) Knee replacement surgery during the reporting period.
National
Highest National
Lowest National
Reporting Periods
(at least last two
Average
Score
Score
reporting periods)
8.444
Apr 12 – Mar 13
15.99
20.37
12.2
The Manor hospital considers that this data is as described which is below the national average and
we will therefore aim to continue maintaining this score.
Unit
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the Manor
hospital within 28 days of being discharged from a hospital which forms part of the hospital during
the reporting period.
Unit
0%
Reporting Periods
(at least last two
reporting periods)
Apr 11 - Mar 12
National
Average
Highest National
Score
Lowest National
Score
11.45
14.35
7.96
The Manor hospital does not see or treat patients aged 0-14 years.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of the
Manor hospital within 28 days of being discharged from a hospital which forms part of the hospital
during the reporting period.
Unit
0%
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 Manor hospital considers that this data is as described and had zero readmissions within
28days of being discharged for the year.
8.4 The Manor hospital’s responsiveness to the personal needs of its patients during the reporting
period.
Unit
96%
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 Manor hospital considers that this data is as described which is above the national average and
we will therefore aim to continue maintaining this score.
8.5 The percentage of patients who were admitted to Manor hospital and who were risk assessed
for venous thromboembolism during the reporting period.
Unit
95%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
The Manor hospital considers that this data is as described. Continuous training is provided to all
clinical staff to improve VTE risk assessment results.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Manor hospital
amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
Lowest National
Score
17.3
30.8
0
The Manor hospital considers that this data is as described and had zero C difficile cases for the
reporting year.
8.7 The number and, where available, rate of patient safety incidents reported within the Manor
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
0
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
0
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 Manor hospital considers that this data is as described and have had zero cases for the
reporting year.
8.8 The percentage of staff employed by the Manor hospital during the reporting period, who would
recommend the Manor hospital as a provider of care to their family or friends.
Unit
98%
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
The Manor hospital considers that this data is as described which is above the highest national
score. We will continue to monitor the percentage.
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 Manor hospital as a provider of care to their family or
friends.
Unit
87.54%
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 Manor hospital considers that this data is as described and is above the national average
percentage of 66.23. We continue to encourage patient to complete questionnaires in order to
increase our response rate.