BMI The Saxon Clinic 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 Today that work has been superseded by the Private Hospitals Information Network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.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 1
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.
Page | 2
Stephen Collier
Chief Executive Officer
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 3
BMI The Saxon Clinic
The hospital has two theatres together with an endoscopy suite / minor theatre, Imaging department,
Physiotherapy, Pharmacy, Oncology Service, Health Screening, Travel Clinic, GP Extra Service and an
Outpatients department with 14 consulting rooms. The hospital is supported by caring and professional
staff, with dedicated nursing teams and Resident Medical Officers on duty 24 hours a day, providing care
within a comfortable environment. The Saxon Clinic also provides fertility services as a satellite of Care
Fertility.
The rolling programme of bedroom and accommodation refurbishment continues. The rooms offer
privacy and comfort of en-suite facilities, satellite TV, Wi-Fi and telephone.
As well as a private patient service we also offer an NHS Choose & Book programme, which patients
may access via their General Practitioner, allowing them to receive consultation and surgery at BMI The
Saxon Clinic through a contract with Milton Keynes Clinical Commissioning Group (CCG). 28% of the
Clinic’s current work load is NHS. In the event a patient’s condition urgently requires specialist care BMI
The Saxon Clinic cannot provide there is an SLA agreement in place with Milton Keynes NHS
Foundation Trust to transfer the patient via paramedic ambulance into their care.
Patient facilities are on one level and briefly comprise of:
•
•
•
•
•
•
•
•
Ward area – 37 beds in single rooms with en-suite facilities.
2 two-bedded rooms with en-suite facilities
Health Screening (Intelligent Health) department and private GP Extra service.
Two operating theatres – one with Lamina flow air controls.
Endoscopy Suite/Minor Theatre 3.
Pharmacy unit providing a service for inpatients and outpatients.
Two imaging rooms providing plain film and fluoroscopy studies and ultrasound. The department
is equipped with digital equipment to provide rapid turnaround voice-recognition reporting. We
have a Fuji PACS workstation which allows image transfer from outside hospitals through IEP.
MRI and CT scanning is provided through an SLA with InHealth group.
Physiotherapy department comprises both individual treatment rooms and a gym.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the Health
& Social Care Act 2008. BMI The Saxon Clinic 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 01 October 2013 and the results are as follows:
•
Management of medicines 8 Action needed
People were not always protected against the risks associated with medicines because the
provider had appropriate arrangements in place to manage medicines in Theatres. We have judged that
this has a minor impact on people who use the service, and have told the provider to take action.
•
Supporting workers 9 Met this standard
The provider was meeting this standard. People were cared for by staff who were supported to deliver care
and treatment safely and to an appropriate standard.
•
Records 9 Met this standard
The provider was meeting this standard. People were protected from the risks of unsafe
or inappropriate care and treatment because accurate and appropriate records were maintained.
Key to icons
All standards were being met when we inspected the service. If this service has not had a CQC
inspection since it registered with us, our judgement may be based on our assessment of declarations and
evidence supplied by the service.
At least one standard in this area was not being met when we inspected the service and we required
improvements.
At least one standard in this area was not being met when we inspected the service and we have taken
enforcement action.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 4
The areas of non-compliance were identified as abstracted in the below table which details the actions
completed by the provider to comply with the regulatory outcome. BMI The Saxon Clinic currently awaits
re-inspection against these measures.
Outcome
number
9
Page | 5
CQC non-compliance
Management of Medicines - Outcome 9
(Regulation 13)
‘Appropriate measures were not in place in
relation to the recording of medicine in
Theatre.’
Action/Recommendations to achieve
Consultant Anaesthetists to have the overall
responsibility for administering medication and
completing all related documentation.
To ensure that the ‘Preparation of Anaesthetics’
SOP is adhered to and compliance to policy
monitored.
To write to Consultants/Anaesthetist detailing
change in current practice. Each Consultant file to
hold copy of correspondence.
To meet with MKCA lead and Private Anaesthetists
to discuss any concerns with implementation.
ODP staff have the responsibility to monitor and
check compliance to the documentation and assist
anaesthetist in the completion.
To ensure that the usage and wastage of medicine
is recorded and checked as part of the WHO
Procedure.
To ensure all Anaesthetic Practitioners have
undertaken the BMI Anaesthetic Practice
competencies. Compliance to the 3 year
competency update will be monitored, and those
outside will have a competency assessment and
review.
Medicine Management and IV Update training is to
be completed by all staff. Compliance will be
monitored and attendance documented in house
systems.
ODP’s to be confident and comfortable in declining
to draw up & administer drugs to ensure
anaesthetists carry out duties.
The CD Register is to be monitored/audited daily to
ensure compliance. The record must display a true
and accurate record of medicine managementincluding clear documentation of usage and
wastage of drugs.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
BMI The Saxon Clinic 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 Director of Infection Prevention and
Control and Group Head of Infection Prevention and Control, in
liaison with the Infection Prevention and Control Lead BMI The
Saxon Clinic.
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.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 6
• SSI data is also collected and submitted to Public Health England for Orthopaedic surgical
procedures. Our rates of infection are:
$SU
0D\
-XQ
-XO
$XJ
6HS
2FW
1RY
'HF
-DQ
)HE
0DU
+LS$UWKURSODVW\66,5LVN&RXQW
+LS$UWKURSODVW\66,5LVN&RXQW
+LS$UWKURSODVW\66,5LVN&RXQW
.QHH$UWKURSODVW\66,5LVN&RXQW
.QHH$UWKURSODVW\66,5LVN&RXQW
.QHH$UWKURSODVW\66,5LVN&RXQW
,QIHFWLRQ&RQWURO
Any audit undertaken at BMI The Saxon Clinic has a narrative summary and action plan where required,
which is distributed to the relevant departments. These are reviewed regularly to ensure actions are
measured, achieved and improvements made where compliance is required. Learning is then shared
and cascaded to teams with the overall aim of improving our patients experience of our services.
The following are Infection Prevention Control (IPC) audits that have been conducted within the reporting
period:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
World Health Organisation (WHO) Hand Hygiene Assessment (January 2014)
Hospital Site self-assessment & associated action plan (January 2014)
Ward Audit -Whole Department (February 2014)
Ward hand hygiene process improvement tool (February 2014)
Theatre Asepsis- Standard Precautions (February 2014)
Theatre Scrub Procedure Surgical (February 2014)
Operating Theatre Asepsis PIT (April 2013)
Central Venous Catheter- Theatre (December 2013)
Catheter Care Bundle Audit- Theatre (Monthly- ongoing)
Urinary Catheter Insertion- Theatre (October 2013)
Peripheral IV Cannula Care Bundle- Theatre (October 2013)
SSI Intra-operative- Theatre (October 2013)
Theatre Hand Hygiene PIT (August 2013)
Mattress and Pillow Audit- Outpatients (February 2014)
Mattress and Pillow Audit- Ward (March 2014)
Imaging PIT standard precautions (May 2014)
Outpatient PIT (September 2013)
Endoscopy Audit (February 2014)
Daniels Healthcare Sharps Audit (November 2013)
There is focused activity with regards to hand hygiene, aseptic non touch technique and other infection
prevention activities. Training for Hand Hygiene (ANTT) is conducted for all staff who work within the
site. This provision is updated regularly as part of the mandatory requirements both through eLearning
and practical sessions and forms part of the clinical competency programme. World Health Organisation
(WHO) Five moments training is delivered within the facility and WHO assessments have been
conducted.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the
cleanliness of our facilities highly.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 7
The graphs below demonstrate how our patients valued both our Room and Bathroom Cleanliness
during their care pathway. Over 90% of our service users found our facilities either very good or
excellent.
Page | 8
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 system for assessing the quality of the patient environment
which uses the same audit tool as NHS Trust sites. It has replaced the 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
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
the care environment and does not cover clinical care provision or how well staff are doing their job. The
results demonstrate how hospitals are performing nationally and locally.
The assessment is measured using a thermometer score encompassing a Pass, Qualified Pass, Fail
and Not applicable grading. We are very proud of the results for BMI The Saxon Clinic as shown below:
Page | 9
Privacy, Dignity and
Wellbeing
100.00%
Food
94.94%
Cleanliness
93.51%
Condition, Appearance
and Maintenance
90.74%
The audit was carried out over a 5-hour period to include all elements requested of the process with
patient assessors having been recruited from within the sites dedicated patient focus group. The day of
audit was both an integrated and enjoyable experience and information was gleamed from our patient
assessors.
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 The Saxon Clinic. 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 our patient’s safety and care. We audit our
compliance with the requirement to VTE risk assess every patient who is admitted to our facility and the
result of our audit for this is 98.33% with the past 9 months of the reporting period demonstrating 100%
compliance.
Here at BMI The Saxon Clinic we aim to continue to maintain our high percentage of patients VTE
assessed by continuing to audit our practice. All staff will continue to receive training as a part of the
induction process and undergo continual development to maintain clinical competencies in line with best
practice. All patients seen at pre-operative assessment are VTE risk assessed and a risk assessment
form completed.
BMI The Saxon Clinic 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.
There have been 0 Venous Thromboembolism (VTE) related incidents for the period of April 2013 to
March 2014 at BMI The Saxon Clinic.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
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 BMI The Saxon Clinic.
Oxford Hip Score average
April 12 –
Mar 13
BMI The
Saxon Clinic
England
Q1
Q2
Health gain between reporting
periods
17.185
40.111
22.926
17.907
39.224
21.317
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
BMI The
Saxon Clinic
England
Q1
Q2
Health gain between reporting
periods
19.906
36.434
16.528
18.893
34.902
16.01
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
We diligently ensure that our NHS patients complete the PROMs questionnaire tool. With the provision
of our Quality Health Solar tool we are now able to draw comparisons of our real time results with other
trusts and providers across the healthcare community. We are able to produce graphs, charts and tables
suitable for reporting back to our staff and clinicians to ensure that learning is shared and where
appropriate improvements can be made
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.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 10
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.
b.
c.
d.
Maintaining good pre-operative hydration
Minimising the risk of post-operative nausea and vomiting
Maintaining normothermia pre and post operatively
Early mobilisation
4. Encouraging patients have an active role in their recovery
a.
b.
c.
d.
Participate in the decision making process prior to surgery
Education of patient and family
Setting own goals daily
Participate in their discharge planning
Our average length of stay, combining all patient demographics, for knee replacement surgery is 2.7
days and for hip replacements this is 2.9, which is very encouraging. We constantly review our top 10
procedures to ensure that patient pathways remain clinically sound with reduced clinical and operational
variances, improving the patient’s experience of our services.
We have developed our ERP by implementing into practice Joint Schools at the pre-assessment stage.
This enhances the patients experience and ensures that expectations are well measured and achieved
throughout their journey. It also draws on expertise from a multidisciplinary team integrated across the
healthcare community including Community Care, Carers and Occupational Therapy to ensure that
support is in place for the patient and their pathway.
Standard activities include but are not limited to discussions around Anatomy / Procedure / Postoperative goals / Expected Length of stay in Hospital and question & answer sessions. A Nurse and
Physiotherapy Assessment which includes Informed Consent , measure for antiǦembolism stockings,
BMI / base line observations, discharge assessment and planning, PROMS, National Joint Registry
(NJR) form, femoral head donation/retrieval consent, patient Information, community Occupational
Therapy referral is organised as required, expected date of discharge confirmed, commencement of
setting discharge goals and the provision of further assessment if an anaesthetic review is required.
A full medication history is taken which includes a review of any Anticoagulant Therapy / Advice when to
stop if necessary, Pain Management, Nutritional Support – Carbohydrate Loading/preloading protocol.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 11
We have fully implemented the ‘My Roles and My Responsibilities, In Helping to Improve My Recovery’
Leaflets as aids for all NHS Hip and Knee Surgery patients undergoing this pathway. To develop this
initiative further we are looking at implementing material of a similar and appropriate nature for both our
Private Medical Insured (PMI) and Self-pay patients to maintain our current successes with ERP.
Page | 12
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.
Unit
April 2013 to March 2014
Unplanned Readmission
<31 Days
Unplanned
Returns to Theatre
4398
18
11
Admissions for period
BMI The Saxon Clinic
Both readmissions <31 days and unplanned returns to theatre are reported on clinical incidents, entered
into our reporting software system and investigated for appropriate practice and trends. There were no
trends to report and all patient care was appropriate
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- Quality
Health.
ϭϮϬ
ϭϬϬ
ϴϬ
ϲϬ
ϰϬ
ϮϬϭϯsĞƌLJ'ŽŽĚ
ϮϬ
ϮϬϭϯdžĐĞůůĞŶƚ
Ϭ
The graph above demonstrates how over 90% of our patients valued aspects of their care pathway as
being either very good or excellent in the 2012/13 reporting period.
In the 2013/14 reporting period we maintained this high standard and rated higher than the national
average for patient service satisfaction. We aim to continue to maintain this high standard of
responsiveness to patient needs and see our patient feedback as a fundamental opportunity to learn,
commend and improve our services.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 13
$W\HDUVRIDJH
WKLVZDVP\ILUVW
RSHUDWLRQWKDW,FDQ
UHFDOO,ZDVYHU\
QHUYRXV6D[RQ
GLVSHOOHGWKHVH
QHUYHV
7KHQXUVLQJFDUHKDV
EHHQH[FHOOHQW
WKURXJKRXW,FDQ
W
SUDLVHWKHVWDII
HQRXJKWKDQN\RX
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
0\QXUVLQJFDUHZDV
VDWLVIDFWRU\DOO
VWDIIZRUNHG
H[FHOOHQWO\WRHQVXUH
WKDW,ZDV
FRPIRUWDEOHDQG
YHU\UHOD[HG
$VDEOLQGSDWLHQW
WKHFDWHULQJVWDII
ZHUHVHQVLWLYHWRP\
QHHGVLHH[SODLQLQJ
ZKHUHIRRGZDVRQ
WKHSODWHSRXULQJ
GULQNVHWF
Page | 14
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI The Saxon
Clinic actively encourages feedback both informally and formally. Patients are supported through a
robust complaints procedure, operated over three stages:
Page | 15
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 below table demonstrates the trends of complaints received at BMI The Saxon Clinic for the 2013/14
reporting period. It shows the processes taken in an attempt to satisfactorily resolve patients concerns
and embed the learning from the outcomes into our practice.
Trend
Financial: Regarding being charged for
services or charged at a higher rate than
expected.
Action taken
Full investigations made, integrated across BMI
services and actions taken as appropriate.
Further training arranged as necessary to each case
and learning shared on any reccomendations made
to practice improvement.
Services not meeting patient expectations
and requesting re-imbursement.
Full investigations made and actions taken as
appropriate.
Further training arranged as necessary to each case
and learning shared on any reccomendations made
to practice improvement.
Patient disatisfaction with their consultant
Full investigations made and actions taken as
appropriate.
Disatisfaction discussed with the individual
consultant and with the Medical Advisory Committee
(MAC) where appropriate.
These incidents are monitored via Practising
Privileges and revalidation/appraisals which are
reviewed if there is no improvement.
Learning shared on any reccomendations made to
practice improvement
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
4. CQUINS
Commissioning for Quality and Innovation (CQUIN)
The CQUIN framework enables commissioners to reward excellent patient care outcomes. This is done
by linking a proportion of the healthcare providers' income, from the commissioner, to the outcomes of
the local quality improvement goals.
To demonstrate the achievement of these, BMI Healthcare extracts hospital information corporately and
regionally to send to the commissioners and The Saxon Clinic submit information on a monthly and
quarterly basis.
Patient data is kept confidential at all times and only statistics and narrative outcomes are sent to the
commissioners.
Goal
Number
Goal Name
Description of Goal
Goal Weighting (% of
CQUIN scheme available)
1
Friends and
Family Test
16.6%
2
NHS Safety
Thermometer
VTE
To improve the experience
of patients in line with
Domain 4 of the NHS
Outcome Framework
To reduce harm.
Quality Domain
(Safety, Effectiveness,
Patient Experience or
Innovation)
Patient Experience
16.6%
Safety
16.6%
Safety
16.6%
Safety
16.6%
Innovation
16.6%
Effectiveness
3
4
5
6
Care Bundle
Audits,
Catheters
Post-Surgical
Remote Follow
Up
Health
Promotion
To reduce avoidable
death, disability and
chronic ill health from
venous thromboembolism
To demonstrate quality
peri-operative care
Digital First, to reduce
unnecessary face to face
appointments
To support healthy
lifestyles and making
every contact count.
Totals:
100%
CQUIN 12/13
At BMI The Saxon Clinic we support eliminating patient harm as set out the ‘Harm Free Care’ (Institute of
Innovation and Improvement, 2011 – 2013). We align ourselves with best clinical practice and aim to
continually measure patient data as set out in the quality standard agenda to improve our care
pathways..
These measures include but are not limited to audit of VTE Assessment and Prophylaxis, Pressure
Ulcers, Falls, Urinary Tract Infections (UTI) in patients with catheters, compliance with the WHO Safer
Surgical Checklist, Making Every Contact Count (MECC), lifestyle interventions and analysis of trends in
safety incidents to protect patients from avoidable harm.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 16
5. National Clinical Audits
BMI The Saxon Clinic was only eligible to participate in National Joint Registry audit and all joint
replacements are submitted to this. BMI hospital data is from page 223 onwards in the National Joint
Registry for England, Wales and Northern Ireland 2013 10th Annual Report. This details surgical data to
31 December 2012 and was first included last year and has been updated as part of the Government’s
transparency agenda. It is based on procedures carried out during the 2012 calendar year and submitted
to the NJR by 28 February 2013. The Results for BMI The Saxon Clinic are as below.
No. of
procedures
No. of
consultants
Consent
rate
Linkability
Average
ASA
Males
patients
Average
age at
operation
192
8
97%
95%
1.9
43%
65.8
10A rated
Acetabular
implant hip
primary
procedures
10A rated
Femoral
implant hip
primary
procedures
0%
68%
Figures based on January 2012 – December 2012
National Joint registry for England and Wales
10th Annual report 2013
We do take part in NCEPOD audits when applicable to our site and we also have an active Clinical Audit
Plan. For example:
•
•
•
•
•
•
•
•
Infection Control (Care Bundles, Cleanliness and Infection surveillance)
Health & Safety
Patient Healthcare records and documentation
Oncology
Pharmacy
Theatre
Pain
Patient discharge
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
One Stop Carpal Tunnel Clinic:
Carpal tunnel syndrome is one of the most common upper limb disorders and can cause tingling,
numbness or pain in your hand, wrist or forearm. Due to an increasing demand for a dedicated Carpal
Tunnel service we aim to introduce a one stop carpal tunnel clinic. This will be led by Mr Andy Hacker,
Consultant Orthopaedic Surgeon who will work closely with both our Physiotherapy and Hand Therapy
departments to ensure patients receive the best treatment from diagnosis through to rehabilitation
ensuring positive experience of the service in line with best practice.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 17
Sentinel Node marking:
We are currently evaluating the introduction of Sentinel lymph node marking as a key technique used in
the staging of certain types of cancer to see if they have spread to any lymph nodes, since lymph node
metastasis is one of the most important prognostic signs. It can also guide the surgeon to the
appropriate therapy and treatment plan.
Enhanced Recovery Programme (ERP)
BMI The Saxon Clinic aim to continue to develop ERP at site as part of Local CQUIN indicator 4.0
patient mobilisation. Patients will be offered a multifactorial risk assessment to identify and address
future falls risk, and will continue to be offered individualised intervention where appropriate. All our
patients who undergo hip and knee surgery will continue to be offered a physiotherapist assessment the
day after surgery and mobilisation at least once a day unless contraindicated. This in combination with
an increased focus on our Joint Schools and supplementary carbohydrate loading will ensure the quality
of our service and improve patient rehabilitation and outcomes.
Medicine Related Safety:
BMI The Saxon Clinic aim to develop and implement plans which result in a 20% increase in the number
of mediation-related safety incidents in line with the 14/15 Local CQUIN 2.0 to improve reporting of
medication-related safety incidents. Reporting and learning from these incidents will improve the early
detection of risks and enable actions to reduce harm for all those who use our services.
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the BMI The
Saxon Clinic for the reporting period.
Unit
N/A
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
We are unable to currently compare summary hospital-level mortality indicator (SHMI) as the HSCIC
data published does not contain the independent sector.
8.2 BMI The Saxon Clinic patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.096%
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
BMI The Saxon Clinic considers that this data is encouraging and demonstrates that we are above the
national average with regards to patient reported outcome measures scores for Groin hernia surgery.
We diligently ensure that our NHS patients complete the PROMs questionnaire tool and aim to improve
on this measure with the provision of our Quality Health Solar tool. We look forward to be able to draw
comparisons of our real time results with other trusts and providers across the healthcare community.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 18
(ii) Varicose vein surgery
Unit
N/A
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
BMI The Saxon Clinic does not currently submit Patient Reported Outcome Measures Scores
(PROMS) for Varicose Vein Surgery.
(iii) Hip replacement surgery
Unit
22.926
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
BMI The Saxon Clinic considers that this data is encouraging and demonstrates that we are above the
national average with regards to patient reported outcome measures scores for Hip Replacement
surgery. We diligently ensure that our NHS patients complete the PROMs questionnaire tool and aim to
improve on this measure with the provision of our Quality Health Solar tool. We look forward to be able
to draw comparisons of our real time results with other trusts and providers across the healthcare
community.
(iv) Knee replacement surgery during the reporting period.
Unit
16.528
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
BMI The Saxon Clinic considers that this data is encouraging and demonstrates that we are above the
national average with regards to patient reported outcome measures scores for Knee Replacement
surgery. We diligently ensure that our NHS patients complete the PROMs questionnaire tool and aim to
improve on this measure with the provision of our Quality Health Solar tool. We look forward to be able
to draw comparisons of our real time results with other trusts and providers across the healthcare
community.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of BMI The Saxon
Clinic 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
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 19
BMI The Saxon Clinic considers this data to be reflective of our continued commitment to deliver a
comprehensive paediatric service that meets the requirements of our younger service users. Paediatric
re-admissions <28 days are admitted to BMI The Saxon Clinic only if a paediatric nurse is on site. If this
is not the case there is an SLA agreement in place with the local Trust to accept paediatric patients as
emergency admissions.
BMI the Saxon Clinic is passionate about creating an integrated pathway for our paediatric patients and
their family. This data is as described due to our patient centered approach to care delivery. We aim to
maintain this high standard of responsiveness and will continue to measure its effectiveness to develop
the pathway where appropriate.
8.3. (ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of BMI The
Saxon Clinic within 28 days of being discharged from a hospital which forms part of the hospital during
the reporting period.
Unit
0.41
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
BMI The Saxon Clinic considers that this data is extremely positive and as described due to our
commitment to ensure the safe and effective delivery of care throughout all stages of the patient journey.
All re-admissions < 28 days were for known clinical complications following primary surgery where the
appropriate pathway was followed to ensure the safety of our patients. BMI The Saxon Clinic aim to
maintain this high standard of care and responsiveness to deliver a positive experience of our services to
our patients.
8.4. BMI The Saxon Clinic responsiveness to the personal needs of its patients during the reporting
period.
Unit
92.57%
Reporting Periods
(at least last two
reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
68.1
84.4
57.4
BMI The Saxon Clinic considers that this data is as described due to our commitment to our patients and
the care in which they receive.
BMI The Saxon Clinic has embraced the 6C integrated strategy for improving quality of care and patient
experience at our facility. Staff have taken ownership of this framework to embed a culture of patient
centered care and are actively dedicated to improving our patient outcomes. We aim to continue to
improve on this high standard of responsiveness to patient needs and will measure its effectiveness to
improve where appropriate.
8.5 The percentage of patients who were admitted to BMI The Saxon Clinic and who were risk assessed
for venous thromboembolism during the reporting period.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 20
Unit
98.33%
Reporting Periods
(at least last two
reporting periods)
Apr 13 – Jan 14
National
Average
Highest National
Score
Lowest National
Score
96
100
79
BMI The Saxon Clinic considers that this data is as described as per the findings of our clinical audits
which demonstrate that there have been 0 Venous Thromboembolism (VTE) related incidents for the
period of April 2013 to March 2014.
Here at BMI The Saxon Clinic we audit our compliance with the requirement to VTE risk assess every
patient who is admitted to our facility. Although the result of our audit for the period was positive at
98.33% the past 9 months have demonstrated 100% compliance.
We aim to continue to maintain our high percentage of patients VTE assessed by continuing to audit our
practice. All staff will continue to receive training as part of the induction process and undergo continual
development to maintain clinical competencies in line with best practice. We see this as an important
initiative to further assure our patients of our commitment to their safety and care.
8.6 The rate per 100,000 bed days of cases of C Difficile infection reported within BMI The Saxon Clinic
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
BMI The Saxon Clinic considers that this data is as described due to our dedication to ensure a safe
environment in which to deliver a high standard of care.
At BMI The Saxon Clinic we have in place an SLA with a Consultant Microbiologist who has substantive
practice in the local Trust. Our dedicated team monitors and audits surveillance data, meeting monthly to
assess any underlying trends in line with our patient outcomes. The aim is to give assurance to the
quality of our services. We are very proud of our dedication to our Infection Prevention and Control (IPC)
strategy and aim to maintain this current standard.
8.7 The number and, where available, rate of patient safety incidents reported within BMI The Saxon
Clinic 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
299
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)
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 21
Unit
6.8%
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
Page | 22
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
BMI The Saxon Clinic considers that this data is as described due to our dedication to ensure a safe
environment in which to deliver a high standard of care.
BMI The Saxon Clinic considers this data to be very encouraging and demonstrates both our
commitment to our patients and our intentions to create a safe and effective care pathway. We aim to
maintain this measure by:
•
•
•
Continuing to have in place a robust process for patient safety incident reporting and
management.
Continuing to have in place a systematic approach to learning.
Continuing to promote a reporting and transparent culture.
8.8 The percentage of staff employed by BMI The Saxon Clinic during the reporting period, who would
recommend BMI The Saxon Clinic as a provider of care to their family or friends.
Unit
93%
Reporting Periods
(at least last two
reporting periods)
2013
National
Average
Highest National
Score
Lowest National
Score
64.58
96.43
33.73
BMI The Saxon Clinic considers that this data is extremely positive and demonstrates that our staff
recognises our dedication to be a passionate and effective provider of care.
We want to go further in understanding our staffs responses and identify areas in which we can improve
by empowering our staff to promote the changes required.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
In line with the National CQUINS for 14/15 BMI The Saxon Clinic aim to have surveyed a minimum of
100% of The Saxon Clinic Staff across all staff groups by the end of Q4.
We will establish a baseline net promoter score in Q1 and agree a trajectory for improvement or
maintenance of our scores. This will enable us to produce a report which shows a concise and thorough
review of the results from the FFT questions, a review of the question ‘what is the main reason for the
answer you have chosen’ and the comments/free text section. We can then ensure that learning is
shared appropriately and where required an action plan completed to implement changes requiring
development.
9. Non-Mandatory Quality Indicator
9.1 The percentage of patients who received care as inpatients or discharged from A &E during the
reporting period, who would recommend BMI The Saxon Clinic as a provider of care to their family or
friends.
Unit
82.18%
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
BMI The Saxon Clinic considers that this data is positive and recognises our dedication to provide high
quality care to our patients. While the unit demonstrates that BMI The Saxon Clinic is above the national
average we strive to improve on this number in line with our National CQUIN 1.3 and 1.4 by improving
the response rate to the FFT questions. This will enable us the opportunity to collate a more concise
view of how patients view our services and take action accordingly.
S.COWELL (CGC) 12/05/2014 (Final V1.2)
S:\ADM-Administration\Clinical Risk\QUALITY ACCOUNTS\2014 MAY
Page | 23