BMI The Sandringham 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 Today that work has been superseded by the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
BMI The Sandringham Hospital has 34 beds
with all rooms offering the privacy and comfort
of ensuite facilities, satellite TV and telephone.
The hospital has a theatre, endoscopy room
and a minor procedures room based in the Out
Patient Department. The hospital has a
Consulting Suite consisting of five Consulting
Rooms, Physiotherapy Department and an
Imaging Department. The Sandringham
Hospital is a purpose built unit, located in the
grounds of The Queen Elizabeth Hospital Trust
in Kings Lynn. The two hospitals have a close
working relationship and provide a range of
technical and professional services.
These on site facilities enable our 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 Resident Medical Officers 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 Orthopaedics,
Urology, General Surgery, Eye Surgery, Dental Surgery, Endoscopy and Gynaecology
54.4% of our overall referrals are NHS patients.
.
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The Sandringham 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 7th October 2013 and found
Fees
Care and Welfare of people who use services
Management of Medicines
Staffing
Assessing and monitoring the quality of service provision
The Sandringham 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. There has been development of
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 Sandringham
Hospital. 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 The Sandringham Hospital..
We have had: -
• Zero cases of MRSA bacteraemia in the last year (NHS 1.17cases/100,000 bed days).
• Zero cases of MSSA bacteraemia cases /100,000 bed days
• Zero cases of 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 0%
o Knees 0%
Every month Infection Prevention and Control carry out audits ranging from reporting any
hospital acquired infections, patient equipment, personal protective equipment and sharp safety.
Care Bundles include prevention of surgical site infections - perioperative actions and peripheral
intravenous cannula. The results ranged from 84 – 100%. Action plans were recorded and
actioned for any audits that required improvement and the same were discussed at Clinical
Heads of Department, Infection Prevention and Control, Clinical Governance and departmental
meetings.
All staff have completed the mandatory eLearning training on infection prevention and control
and have attended practical training on hand hygiene. ANTT training is in progress at present.
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)
April 2013
Cleanliness
99.68%
Food and
Hydration
91.89%
Privacy, Dignity
and Wellbeing
90.91%
Condition
Appearance and
Maintenance
91.33%
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.
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 Sandringham Hospital. BMI Healthcare was awarded
the Best VTE Education Initiative Award category by Lifeblood in February 2013 and were the
Runners up in the Best VTE Patient Information category.
We see this as an important initiative to further assure patient safety and care. We audit our
compliance with our requirement to VTE risk assessment every patient who is admitted to our
facility and the results of our audit on this has shown 100% compliance with every patient
receiving a VTE assessment.
The Sandringham 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. .
At The Sandringham Hospital we have had no incidents of DVT or PE reported to us within the
past 12 months.
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 Sandringham Hospital. In the PROMS results
published March 2013 BMI The Sandringham Hospital was ranked 12th in the UK for Primary
Hip Replacement ranked by mean adjusted Oxford Hip Health Gain Score.
Oxford Hip Score average
2012
The
Sandringham
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
19.125
41.125
22
0.339
0.767
0.429
England
Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'
Oxford Knee Score average
2011/2012
The
Sandringham
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
19.988
37.965
17.977
0.387
0.709
0.321
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 comorbidities, medication assessment – stopping medication plan.
d. Commencement of discharge planning
3. Proactive patient management
a. Maintaining good pre-operative hydration
b. Minimising the risk of post-operative nausea and vomiting
c. Maintaining normothermia pre and post operatively
d. Early mobilisation
4. Encouraging patients have an active role in their recovery
a. Participate in the decision making process prior to surgery
b. Education of patient and family
c. Setting own goals daily
d. Participate in their discharge planning
The average length of stay for our total hip replacements is 2.6 days and 3 days for our total
knee replacements. We are top within all of our BMI sites and have been able to achieve this
through dedicated patient focus, excellent communication with our patients and all staff involved
prior to admission to post discharge follow up, effective and manageable pain control and the
determined support and encouragement from our physiotherapy team.
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.
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.
March 2014
The Sandringham Hospital
Excellent %
Very Good %
Overall Impression of Admission
71.8%
21.8%
Overall Impression of Consultant
88%
10%
Overall Impression of Nursing
86%
11.7%
Overall Impression of Catering
69.7%
22%
Overall Impression of Discharge
69.1%
21.4%
Overall Impression of Quality of Care
83.8%
12.6%
Overall Impression of Accomodation
73.6%
22%
How likely to recommend to Friends and
Family
86.1%
11.8%
We encourage our patients to be 100% honest with their responses as we look at any
feedback as an aid to assist us in continually addressing our processes and pathways to
achieve a better outcome for the patient.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
The Sandringham 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.
4. CQUINS
Last year CQUINS we recorded and audited were:
•
Friends and Family Test
•
NHS Safety Thermometer
•
VTE Risk Assessment
•
Catheter Care Bundles
•
Post-Surgical Follow up
•
Lifestyle Intervention BMI >30
•
There were marked improvements throughout the year in relation to Post Surgical Follow up
and Lifestyle Intervention. There was a slight decrease in the catheter care bundles for one
month only – all other months were 100% compliant. All other CQUINS were achieved 100%.
5. National Clinical Audits
The Sandringham 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
•
•
•
•
At present we are looking at investing in ophthalmology laser equipment to enable us to
perform Laser Capsulotomy, Laser Iridotomy and Laser Trabeculoplasty in the Out
Patient Department.
We are also recommencing Patient Focus Groups to enable us to improve our service
through the voice of our patients.
We have recently recruited a highly experienced Infection Prevention and Control Lead
who will working along with The Director of Infection Prevention and Control within the
hospital to ensure we maintain an excellent audit and reporting regime, the highest level
of training and support to all staff and an environment that is above standard for all
infection prevention and control requirements.
Health Promotion is high on our clinical agenda with implementation of educational
information to all patients who smoke or have a BMI >30. We also ensure this
information is documented and reported to the GP to ensure continuity of care is
maintained.
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
Sandringham Hospital for the reporting period.
Unit
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 Sandringham Hospital is unable to complete this information as the HSCIC data does not
contain the independent sector for this
8.2 The Sandringham Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.067
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
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
(ii) Varicose vein surgery
Unit
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
There were no scores for Varicose Veins for BMI Healthcare
(iii) Hip replacement surgery
Unit
22.23
Reporting Periods
(at least last two
reporting periods)
Apr 12 – Mar 13
As a united team we ensure that the patient receives clear instruction and guidance on the
pathway they will be following. This commences from their first appointment in Outpatients
through to their discharge from the hospital and any community care that may be required. The
whole hospital team are congruent in their patient focus. They ensure that the patient is
provided with an informative, structured and individual pathway that has been discussed and
created with the patient therefore enabling a productive partnership to achieve the excellent
results that we as a hospital are proud to deliver.
(iv) Knee replacement surgery during the reporting period.
Unit
18.38
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
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the
Sandringham 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
BMI The Sandringham Hospital does not admit any patients under the age of 18 for any
inpatient or outpatient activity.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the Sandringham Hospital within 28 days of being discharged from a hospital which forms part
of the hospital during the reporting period.
Unit
0.177%
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
8.4 The responsiveness to the personal needs of its patients during the reporting period.
Unit
94.69%
Reporting Periods
(at least last two
reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
8.5 The percentage of patients who were admitted to Sandringham Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
100%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
All patients are risk assessed on admission and then daily at The Sandringham Hospital.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the
Sandringham 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
8.7 The number and, where available, rate of patient safety incidents reported within the
Sandringham 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
53
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
2.42
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
8.8 The percentage of staff employed by the Sandringham Hospital during the reporting period,
who would recommend the Sandringham Hospital as a provider of care to their family or friends.
Unit
49%
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
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 Sandringham Hospital as a provider of care to
their family or friends.
Unit
88.55%
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 Sandringham Hospital has consistently received positive feedback from this area. As a
smaller unit we are proud that there is a close working relationship with all the staff. Patients
and relatives do comment on the pleasant, friendly atmosphere that they experience when they
attend the hospital. Please find below comments from our patients:
“The entire team here have excelled in all personal care of myself in every way possible and I
owe them all a very great vote of thanks.”
“All staff that I came into contact with were excellent they could not be bettered.”
“All nurses were attentive and caring. Couldn't do enough. Nothing too much trouble.”
“All staff in every department gave excellent care.”