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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 Today that work has been superseded by the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.
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Stephen Collier
Chief Executive Officer
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BMI The Sloane Hospital in Beckenham, Kent is part of BMI Healthcare, Britain's leading provider of independent healthcare with a nationwide network of hospitals & clinics performing more complex surgery than any other private healthcare provider in the country. Our commitment is to quality and value, providing facilities for advanced surgical and medical procedures together with friendly, professional care.
The Sloane Hospital has a state of the art diagnostic imaging department and a pro-active physiotherapy department. Our Consulting rooms are modern and well equipped including a nurse led pre admissions service.
The Sloane Hospital has 32 beds with rooms offering the privacy and comfort of en-suite facilities, satellite TV Wi Fi and a telephone. The hospital has two theatres (one with laminar flow) and can provide High Dependency care.
These facilities combined with the latest in technology and on-site support services, enable our consultants to undertake a wide range of procedures from routine investigations to complex surgery. The majority of surgical specialties are accommodated at The Sloane including neuro surgery, Orthopaedics, cosmetic surgery, Gynaecology, general surgery, gastroenterology, ENT surgery, vascular surgery, and Ophthalmology.
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. An emergency medical admissions service is available 24 hours a day supported by leading medical physicians.
The Sloane Hospital is engaged in providing some NHS Standard Contract Choose and Book service cover, with published offerings in Trauma and Orthopaedic, Neurosurgery and pain management services. The hospital also engages in a variety of periodical contract work with local NHS Trusts. NHS work currently accounts for around 5 % of the Sloane Hospitals activity.
% of NHS patients to overall work and any other relevant info about NHS work
BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI The Sloane is registered as a location for the following regulated services:-
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•
Treatment of disease, disorder and injury
•
Surgical procedures
•
Diagnostic and screening
The CQC carried out an unannounced inspection on
Date of Inspection: 21/11/13 Date of Publication: 7/01/14
Respecting and involving people who use Services: Met this standard
Care and welfare of people who use services: Met this standard
Safeguarding people who use services from Abuse: Met this standard
Supporting workers: Met this standard
Assessing and monitoring the quality of service Provision: Met this standard
The Sloane 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 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.
There are external reporting requirements for CQC, Public Health England (Previously HPA)
CCGs and Insurers. There has also been ongoing progress on the project to collect and publish comparative data to assist patients and referrers with their choices on healthcare facility. This has started with the launch of an independent Private Healthcare Information Network website
ŚƚƚƉ͗ͬͬǁǁǁ͘ƉŚŝŶ͘ŽƌŐ͘ƵŬ This provides information on facilities, numbers of a variety of procedures carried out at each site and some basic quality indicators. The range of the available indicators will continue to grow for ongoing enhancement of choice.
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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 Sloane 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 in the
Sloane 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
•
One case of E.coli bacteraemia / 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 : no SSI in the last twelve months o Knees: no SSI in the last twelve months
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The Sloane Hospital uses care bundles as a means of documenting
interventions in the areas of :
Surgical site care
Urinary catheter care
Intravenous peripheral lines
Surgical site infections
These interventions are audited by departmental infection control links, infection control audits are completed monthly as part of a rolling corporate program, with different themes each month, for example Sharps management, Surveillance, waste management, isolation facilities and equipment cleansing with compliance averaging 92%.
All clinical staff undergo annual mandatory training and practical competency based assessment in ANTT (Aseptic non touch Technique) for clinical intervention.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly.
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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.
Our results for 2013 are on table below:
>E>/E^^
100.00%
&KKE
,zZd/KE
93.24%
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/'E/dz
E t>>/E'
84.78%
KE/d/KE
WZE
E
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91.67%
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Overall The Sloane was well above the national average for most outcomes. We are due to be re audited in the next six weeks.
Venous Thrombo-embolism (VTE)
BMI Healthcare, holds VTE Exemplar Centre status by the Department of Health across its whole network of hospitals including, The Sloane 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 consistency in good practice. month
April 2013
May 2013
June 2013
July 2013
Aug 2013
Sept 2013
Oct 2013
Nov 2013
Dec 2013
Jan 2013
Feb 2014
March 2014
VTE
100%
99%
100%
100%
100%
100%
92%
100
100%
100%
100
100
The Sloane 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. We have had no reported cases of VTE. In order to maintain our results we have run clinical updates on VTE and good practice for the ward teams, we report monthly our audit data via the Clinical Governance team which is then feedback to the staff.
2.1 Patient reported Outcomes (PROMS)
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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 Sloane Hospital. The latest results from April to
December are published.
The Sloane Hospital participates in data collection, however has Insufficient numbers to generate data. Participation is not obligatory however we are working on ways to improve our participation rates where able .
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Oxford Hip Score average
2013
Q1 Q2 Health gain (Q2 - Q1 average)
Insufficient numbers to produce
The Sloane
Hospital data
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
2013
Q1 Q2 Health gain (Q2 - Q1 average)
Insufficient numbers
The Sloane
Hospital to produce data.
0.387
0.709
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
0.321
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
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3. Proactive patient management a. Maintaining good pre-operative hydration b. Minimising the risk of post-operative nausea and vomiting c. Maintaining normothermia pre and post operatively d. Early mobilisation
4. Encouraging patients have an active role in their recovery a. Participate in the decision making process prior to surgery b. Education of patient and family c. Setting own goals daily d. Participate in their discharge planning
The Sloane Hospital ERP committee is in place. Carbohydrate loading drinks are to be introduced by the end of 2014. We have monthly review of our ERP data and feedback of our
ERP audit data is done via our clinical governance team. We are looking at ways to introduce joint schools for our patients by working with teams at other BMI sites within our cluster.
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. Increased awareness in data collection has improved accuracy of our data and incident reporting.
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Ϭ͘ϯϱϬ
Ϭ͘ϯϬϬ
Ϭ͘ϮϱϬ
Ϭ͘ϮϬϬ
Ϭ͘ϭϱϬ
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Ϭ͘ϮϳϮϵ Ϭ͘ϮϳϮϳ
Ϭ͘ϮϬϱϱ
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ϮϬϬϵ
ϮϬϭϬ
ϮϬϭϭ
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ϮϬϭϯ
ϮϬϭϰ
3.1 Patient satisfaction
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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.
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.
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To support engagement and improvement in improving our quality Health results The Sloane hospital holds alternate monthly Pain meetings and patient journey meetings. These are minuted meetings with focused action plans and have members from across the multi disciplinary team both clinical and non clinical. The Sloane hospitals excellent overall average of nursing care score of 97% and Quality of care score of 97% for example demonstrates the effectiveness off our inhouse training and culture of our teams.
3.2 Complaints
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In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
^ůŽĂŶĞ 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.
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* VTE assessment and prophylaxis delivered: average 95 to 100%
* Smoking cessation education: 100% of pre assessed patients are given this information and support.
The Sloane 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.
No NHS patients were recruited to take part in research.
We are near the end of completing a major ward refurbishment including installing a large wet room in one of the patient rooms, replacing all carpeted areas with laminate flooring and replacing patient lockers.
We are scheduling a review of all pre assessment services to seek opportunities to further develop the team and the availability of the service currently offered.
We are developing our inhouse training and seeking opportunity to promote eg dementia care/end of life training updates.
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the The
Sloane Hospital for the reporting period is not available until oct this year. However we have no reported expected or unexpected peri operative deaths.
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the The
Sloane for the reporting period.
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Unit
Value and
Banding
Reporting Periods
(at least last two reporting periods)
Oct 11 – Jun 13
National
Average
1.0006
Highest National
Score
1.1822
Lowest National
Score
0.6735
8.2 The Sloane Hospitals patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
NT437 *
Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
0.083
Highest National
Score
0.157
Lowest National
Score
0.014
The Sloane Hospital is not able to report its score as * = less than 30 patients going through the process, meaning that the site cannot be scored.
(ii) Varicose vein surgery
Unit
NT437 *
Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
-8.738
Highest National
Score
8.172
Lowest National
Score
-15.918
The Sloane Hospital is not able to report its score as * = less than 30 patients going through the process, meaning that the site cannot be scored.
Hip replacement surgery
Unit Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
21.280
Highest National
Score
24.684
Lowest National
Score
17.214 NT437 *
The Sloane Hospital is not able to report its score as * = less than 30 patients going through the process, meaning that the site cannot be scored.
(iii) Knee replacement surgery during the reporting period.
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Unit Reporting Periods
(at least last two
National
Average
Highest National
Score
Lowest National
Score
NT437 * reporting periods)
Apr 12 – Mar 13 15.99 20.37 12.2
The Sloane Hospital is not able to report its score as * = less than 30 patients going through the process, meaning that the site cannot be scored.
8.3 (i) The Sloane Hospital does not admit children under the age of 16 and therefore does not have any data to report
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of the Sloane Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period.
Unit
NT 437 *
Reporting Periods
(at least last two reporting periods)
Apr 11 – Mar 12
National
Average
10.01
Highest National
Score
14.51
Lowest National
Score
5.54
The Sloane Hospital does not admit children under 16 years of age and can demonstrate that the re admission rates are below the national average.
8.4 The Sloane Hospital responsiveness to the personal needs of its patients during the reporting period.
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Unit Reporting Periods
(at least last two reporting periods)
2012-2013
National
Average
Highest National
Score
Lowest National
Score
92% 68.1 84.4 57.4
The Sloane hospital considers that this data is as described for the following reasons we have excellent patient to staff ratios with attention given to continuity of care.
8.5 The percentage of patients who were admitted to The Sloane Hospital and who were risk assessed for venous thromboembolism during the reporting period.
Unit
99%
Reporting Periods
(at least last two reporting periods)
Apr 13 – Jan 14
National
Average
96
Highest National
Score
100
Lowest National
Score
79
The Sloane 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. We have had no reported cases of VTE. In order to maintain our results we have run clinical updates on VTE and good practice for the ward teams, we report monthly our audit data via the Clinical Governance team which is then feedback to the staff.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Sloane
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
17.3
Highest National
Score
30.8
Lowest National
Score
0
8.7 The number and, where available, rate of patient safety incidents reported within the Sloane
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 Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
44.55
Highest National
Score
1,810 153
Rate of patient safety incidents reported (Incidents per 100 Admissions)
Lowest National
Score
0
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Unit Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
Highest National
Score
3.5 7.76 30.95
Number of patient safety incidents that resulted in severe harm or death
Lowest National
Score
1.68
Unit
0
Unit
0
Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
0.64
Highest National
Score
28
Lowest National
Score
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100
Admissions)
Reporting Periods
(at least last two reporting periods)
Apr 12 – Mar 13
National
Average
0.9
Highest National
Score
2.9
Lowest National
Score
0.0
8.8 The percentage of staff employed by the Sloane hospital during the reporting period, who would recommend the Sloane Hospital as a provider of care to their family or friends.
Unit
71%
Reporting Periods
(at least last two reporting periods)
2013
National
Average
64.58
Highest National
Score
96.43
Lowest National
Score
33.73
9.1 The percentage of patients who received care as inpatients or discharged from A &E during the reporting period, who would recommend the Sloane Hospital as a provider of care to their family or friends.
Unit Reporting Periods
(at least last two reporting periods)
Jun 13 – Jan 14
National
Average
66.23
Highest National
Score
94.38
Lowest National
Score
35.63 77%
The patient journey team are focusing on improving response rates as this is having a significant effect on our results.
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