BMI The Somerfield Hospital Quality Accounts April 2013 to March 2014 Chief Executive’s Statement Welcome to our Quality Accounts 2014, the fifth year we have published this data. The information presented here on a broad range of quality measures continues to grow in importance and usefulness for patients and commissioners. Quality accounts already provide a key metric for people to assess the strength of our 66 hospitals and clinics against other facilities - NHS and independent - from which they might receive their care. For BMI Healthcare and every other private provider the importance of comparable quality data was recently reinforced by the conclusions of the Competition Commission’s market investigation into private healthcare. From the outset of the inquiry BMI Healthcare supported the principle that competition in the sector would be enhanced if private hospitals produced comparable quality data, and that competition amongst hospitals would drive up service standards. We were therefore fully supportive when the Commission announced in April that it is mandating the provision of greater information on the performance of hospital operators and consultants. We wholeheartedly agree when the Commission says that “a more transparent market with patients actively making choices will drive hospital operators to compete on the things that matter to patients”. Whilst we are yet to see how the Commission will ensure that this is enacted, the private sector continues to take its own steps. Five years ago BMI Healthcare was at the forefront of the sector’s efforts to be more open about sharing comparable quality and pricing data when we sponsored the launch of the Hellenic Project. Today that work has been superseded by the Private Hospitals Information Network which is working towards publishing data that will allow patients and commissioners to make informed choices - a challenge that the sector must now rise to. We at BMI Healthcare will continue to play our part in these important developments, which we believe can have a significant role in driving higher quality standards. I remain proud, but certainly not complacent, about the quality of care our hospitals provide. Last year BMI Healthcare invested £40m in our hospitals, supporting our committed staff and consultants to meet the challenge of providing consistently safe, high quality care. We constantly measure our patients’ experience, and I am pleased to note that in the three months to the end of March 2014, 97.3% of patients independently surveyed expressed satisfaction with their care and 97.9% said they would recommend us to others. There is however always room for improvement, and publication of comparable quality data across the independent sector can only help. The information available in these quality accounts has been reviewed by the Clinical Governance Board and I declare that as far as I am aware the information contained in these reports is accurate. I thank all the staff whose energy and devotion to improvement is represented here and, more importantly, in the experiences of every patient who steps across our threshold. Stephen Collier Chief Executive Officer Hospital Information The Hospital BMI The Somerfield Hospital which spans over 2 floors offers up to 38 en-suite rooms and provides a range of surgical and medical treatments. The facilities include an inpatient, day ward and two rooms that can offer High Dependency care for levels 1 and 2. We have approximately 130 well-respected local Consultants offer inpatient services for Orthopaedic, Urology, Gynaecology, Oncology, Ophthalmic, Gastroenterology, ENT, Colorectal, Breast, General Surgery, Medicine and Plastic Surgery. The Operating Suite comprises of 3 Operating Theatres including Endoscopy facilities and a Recovery Room. A fully accredited BMI Unit off-site provides decontamination services. Pathology Services, Pharmacy and Physiotherapy Departments support these services, together with Diagnostic Imaging, including Mammography, Ultrasound, Bone Densitometry CT and MRI. The Audiology Department offers hearing tests and a hearing aid fitting and supply service. A Dental Implant service is provided in the Dental Suite. Our Outpatient services also include Dermatology, Endocrinology and Diabetes, Neurology, Paediatrics and Rheumatology. In-patient care is offered by a team of well-educated, skilled and professional nurses led by a Director of Clinical Services, provides individual care to patients. The High Dependency Unit is staffed by nurses with Critical Care Training led by a Sister. Outpatient services are provided in the Consulting Suite, comprising 9 Consulting Rooms and 3 Treatment Rooms, these facilities were upgraded in 2013. Volumes In 2013-14 36% of NHS patients to overall work, we also completed SPOT contract work for Maidstone & Tunbridge Wells NHS Trust for Orthopaedic patients and MRI scans for Medway NHS Trust. BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the Health & Social Care Act 2008. BMI The Somerfield Hospital is registered as a location for the following regulated services:• • • • Treatment of disease, disorder and injury Surgical procedures Diagnostic and screening Family Planning The CQC carried out an unannounced inspection on 3rd February 2014 and found no noncompliances in regards to: Standards of treating people with respect and involving them in their care Standards of providing care, treatment & support which meets people's needs Standards of caring for people safely & protecting them from harm Standards of staffing Standards of Quality and suitability of management This was an extremely positive inspection which was reflected in our report. The Somerfield 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. Development of learnings shared and actions agreed is then cascaded to all hospitals to implement where necessary. 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 Somerfield 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 at The Somerfield Hospital. We have had: • Zero cases of MRSA bacteraemia in the last year (NHS 1.17cases/100,000 bed days). • One MSSA bacteraemia cases /100,000 bed days • Zero E.coli bacteraemia cases/ 100,000 bed days • Zero number of cases of hospital apportioned Clostridium difficile in the last 12 months. Audits The following audits were completed:Mattress audit - Checking of all mattresses within the wards and Pre-admission clinic, there is a programme of mattress replacement. Sharps audit – Completed August 2013, annual check by Daniels Representative for all clinical areas to assess compliance in the use of sharps containers. We obtained over 96% compliance for all departments audited. Areas for improvement included, inappropriate items in the sharps container, and incorrect assembly. Action plans received from relevant departments and discussed at our IPC meetings. All clinical departments are involved in IPS audits on an annual basis. The audits cover general IP&C management as well as cleanliness, hand hygiene, PPE, waste, sharps, and linen management, standard precautions etc. Each section is given a percentage score and then an overall score is calculated. Action plans are requested for areas where improvement is required for any score below 80%. During the year the theatres scored low in some areas, there was a very large amount of work undertaken to ensure compliance and this has now been achieved and maintained. For all staff with direct patient contact, hand hygiene workshops are held at regular intervals with a hand hygiene competency document included. This is ongoing and compliance audits have been completed in clinical areas by department IP&C Links At the training staff are asked to consider their own areas of practice and to report any concerns re-accessing hand decontamination products at the point of care. Compliance audit results suggest that hand gel is readily available. ANTT is moving to a standardised practice as directed by Stephen Rowley and his organisation’s assessment tools and method of training will be implemented. My infection control nurse has started training in this area and posters are being used outlining the concept of “key parts” and “key sites” for aseptic procedures have been circulated to the ward, theatre, and OP departments. These posters provide a visual reminder of the essential steps in a procedure and best practice for avoiding cross-infection. Care Bundles - High Impact Care Bundles are completed regularly in appropriate clinical areas for urinary catheter/peripheral cannula insertion and ongoing management, for prevention of surgical site infection and central lines. Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly. 1.2 Patient-Led Assessments 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 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. The PLACE audit was completed in April 2013 and 3 patients took part alongside 3 staff members and the results were positive. An action plan was implemented following the audit and actions completed. Some of the actions included better internal signage, painting in different areas of the hospital and review of documentation patient’s receive. Cleanliness Food Privacy, Dignity and Wellbeing Condition Appearance and Maintenance 98.92% 98.05% 87.69% 88.52% 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 Somerfield 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 by assessing 20 sets of patient notes. The results of our audit have shown high compliance of a yearly average of 93%. These results findings are discussed at every ward meeting and staff are reminded routinely about completing all risk assessments. In the forthcoming year every NHS patients VTE assessment will be assessed for completion. The Somerfield 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. There was 1 reported DVT and 1 PE during April 2013 and March 2014 the patients had all appropriate risk assessments and prophylactic treatment. 2. Effectiveness 2.1 Patient reported Outcomes (PROMS) Patient Reported Outcome Measures (PROMs) are a means of collecting information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. PROMs is a Department of Health led programme. For the current reporting period, the tables below demonstrate that the health gain between Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing hip replacement and knee replacement at The Somerfield Hospital. Oxford Hip Score average April 2012 – March 2013 The Somerfield Q1 Q2 Health gain (Q2 - Q1 average) 17.417 39.167 21.75 17.907 39.224 21.317 England Copyright © 2011 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.' Oxford Knee Score average April 2012 – March 2013 The Somerfield Q1 Q2 Health gain (Q2 - Q1 average) 21.278 38.556 17.278 17.907 39.224 21.317 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 hospital has an ERP committee that meet every 6-8 weeks this is led by the Hospitals Physiotherapy Manager. During these meeting we review the patient journey from booking through to discharge, looking at the information and advice given to patients, the care they receive, and the engagement with patients and consultants to ensure their help with delivering enhance recovery. For certain procedures we get length of stay data from our ERP Lead for the company, which we review and look at the pathway of those patients to see if we can or need to reduce their stay for their benefit. E.g. our hip and knee replacement patients the hospital LOS is between 3-4 nights this has reduce dramatically since we started the ERP Committee 2 years ago. We have focused on patient education, early mobilization, carbohydrate loading, appropriate analgesia and planning discharge from the offset. By reducing a patient’s length of stay and getting them mobilizing earlier this helps reduce the risk of VTE, infection and helps towards a smoother recovery. 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. Our figures remain very low. 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. Patient satisfaction results – for all patients Year 2012 2013 2014 Nursing Care 98.8% 97.6% 96.7% Arrival process 98.5% 96.9% 95.0% Accomodation 97.3% 96.2% 89.5% Catering 97.8% 94.9% 92.5% Discharge procedure 97.0% 93.9% 91.5% Quality of Care 99.1% 98.0% 96.8% We have a Quality team which meets regularly, the team reviews the patient journey and compares this with the Operational Excellence Standards for the company. We also review the patient comments and agree on action to be taken if needed. This year there has been a big focus on obtaining response, we feel the more patients views we receive it gives us a better insight into the patients perception. From looking at the patient comments on the questionnaire the actions below were implemented Action of focus Key deliverables Increasing Introduction of quality notice board in OPD – to show patients the response rate in questionnaire and remind all to complete. OPD Greeting at Reception manager re-training all staff on greetings and handling of reception patients at reception Nursing care Attend call buzzers immediately / if staff are busy ward clerks to answer then get a suitable nurse if required. To ensure patients are kept informed e.g. - time of theatre / changes to treatment Discharge Catering Physio TTOs to be prescribed and dispensed straight after their surgery especially for D/Cs Discharge planning to start at Pre-admission stage When discharging the nurses will ensure that time for questions is given Nurses are to confirm how the patients is getting home and offer to arrange a cab or call their family if required – at all times patients must know what is happening Servery staff to ensure that all appropriate menus are given directly to the patient / Close attention to portion control To ensure continuity of staff working on the wards Patients get information booklet on admission, to ensure patients get exercise sheets also. Housekeeping Environment Staffing Housekeepers to make sure they have their bleeps so they can be contacted readily. Painting is needed on door frames, some rooms and bathrooms need redecorating – new painter and decorator role advertised The hospital is to remain clutter free – each HOD to make sure that there area is tidy and unwanted items removed Departmental meeting agenda and minute template to be standardised to ensure all appropriate information is cascaded to staff. Each HOD to make sure quality scores are fed-back and discussions are held around why the score has changed and action agreed. 3.2 Complaints In addition to providing all patients with an opportunity to complete a satisfaction survey BMIdŚĞ ^ŽŵĞƌĨŝĞůĚHospital actively encourages feedback both informally and formally. Patients are supported through a robust complaints procedure. 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. Listed below are the complaints received for the period of April 2013 – March 2014 from NHS patients. DATE COMPLAINT RECEIVED 28/11/2013 NHS Inpatient 06/01/2014 NHS Outpatient SUMMARY OF COMPLAINT Patient complained regarding his care, particularly from an anaesthetist following a routine hernia repair. This patient complaint was responded to in line with his stay here, but in the main the majority of the complaint referred to his Consultant Anaesthetist following his transfer into Maidstone Hospital. Patient complained following cancellation of her procedure due to her high BMI. DATE COMPLAINT RESOLVED 10/12/2013 OUTCOME Not Upheld 13/01/2014 Not Upheld Both complaints were not upheld both patients were written to and given full rationale in regards to our decision, the complaints were not escalated. 4. CQUINS Mandatory CQUINS: Indicator Description of CQUIN Target Yearly Score Achieved VTE Review 20 sets of notes to ensure VTE risk assessment are being completed 95% 93% Friends and family test Increase the response rate in patient surveys 20% 24% Question asked to patient “How likely are you to recommend our hospital to friends and family if they need similar care or treatment” 96% 98.5% Local CQUINS Indicator Description of CQUIN Target Yearly score Achieved Dementia Every inpatient 75 and over to have a dementia risk assessment and if required referred back to their GP 97% 100% Number of attendance questioned regarding their smoking and given a leaflet about local smoking cessation services 95% 100% Number of patients referred to local smoking cessation services 90% 100% 5 questions chosen from the patient satisfaction questionnaire – to show an improvement in overall scores over the year 97% 97% Smoking Patient experience 12 patients assessment / 1 referral 5. National Clinical Audits The Somerfield 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 including the following data: • 110 procedures performed by 5 orthopaedic consultants • 100% consent rate • 91% linkability of proportion of records including a valid NHS number compared to numbers on NJR • 47% Male patients • Average age 68.4 6. Research No NHS patients were recruited to take part in research. 7. Priorities for service development and improvement Pre-admission We completed a review of our Pre-admission service which included looking at documentation, local policies, our criteria and current processes this has enabled us to make positive changes to ensure that our patients receive an even smoother and efficient service. For example we have introduced a protocol for the management of patients on anticoagulants prior to their surgery. Refurbishment The hospital has an ongoing programme for refurbishment, during the year we have painted a number of areas. It has made the hospital look fresh airy and patients have given us very positive feedback. Marketing events We undertake quarterly marketing event for GPs, in the last year we completed an ophthalmic event which 50 local GPs attended. Five of our Consultants spoke about different conditions, the feedback we had back was so positive and due to this we are completing another. Staff and Consultant Surveys A survey was sent to both our Consultant and staff to ask for their thoughts about the company and hospital. The feedback gave us real insight into their perception and enables us to implement changes if required. The last staff survey highlight that staff felt they do not always know the changes that are happening in the hospital. As a management team we decided to implement key actions which were: • Starting a daily huddle on the ward at 9am each day to talk through the inpatients needs and discuss any other department issues • Implementing more newsletters to staff from the ED about recent changes • Regular staff forums and open door days so staff can ask questions • Holding regular Staff Focus Group meetings so staff can have a say in events and changes within the hospital As discussed during this report we have also continued to focus on VTE assessment, ERP management, review of meetings we hold such as Resus is now jointly held with the Critical Care Service meeting. 8. Mandatory Quality Indicators 8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the reporting period. Unit Value and Banding 8.2 Reporting Periods (at least last two reporting periods) N/A National Average 1.006 Highest National Score 1.1822 Lowest National Score 0.6735 The Somerfield Hospital patient reported outcome measures scores for (i) Groin hernia surgery Unit Reporting Periods (at least last two reporting periods) April 12-March 13 * National Average 0.083 Highest National Score 0.157 Lowest National Score 0.014 Less than 30 patients going through the process, site cannot be scored (ii) Unit N/A Varicose vein surgery Reporting Periods (at least last two reporting periods) National Average Highest National Score Lowest National Score (iii) Unit Hip replacement surgery Reporting Periods (at least last two reporting periods) April 12-March 13 * National Average 21.280 Highest National Score 24.684 Lowest National Score 17.214 Less than 30 patients going through the process, site cannot be scored (iv) Unit Knee replacement surgery during the reporting period. Reporting Periods (at least last two reporting periods) April 12-March 13 * National Average 15.99 Highest National Score 20.37 Lowest National Score 12.2 Less than 30 patients going through the process, site cannot be scored 8.3 (i) Unit Reporting Periods (at least last two reporting periods) N/A % 8.3. Reporting Periods (at least last two reporting periods) N/A % Highest National Score Lowest National Score National Average Highest National Score Lowest National Score The Somerfield Hospital responsiveness to the personal needs of its patients during the reporting period. Unit 92.55 National Average (ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of the The Somerfield Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Unit 8.4 The percentage of patients aged 0-14 readmitted to a hospital which forms part of The Somerfield Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Reporting Periods (at least last two reporting periods) 2012-2013 National Average 68.1 Highest National Score 84.4 Lowest National Score 57.4 8.5 The percentage of patients who were admitted to The Somerfield Hospital and who were risk assessed for venous thromboembolism during the reporting period. Unit 93% 8.6 Reporting Periods (at least last two reporting periods) April13-Jan 14 National Average 96 Highest National Score 100 Lowest National Score 79 The rate per 100,000 bed days of cases of C difficile infection reported within The Somerfield Hospital amongst patients aged 2 or over during the reporting period. Unit 0 8.7 Reporting Periods (at least last two reporting periods) April 12-March 13 National Average 17.3 Highest National Score 30.8 Lowest National Score 0 The number and, where available, rate of patient safety incidents reported within The Somerfield Hospital during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. Number of patient safety incidents reported Unit 0 Reporting Periods (at least last two reporting periods) April 12-March 13 National Average 44.55 Highest National Score 1,810 Lowest National Score 0 Rate of patient safety incidents reported Unit 0 Reporting Periods (at least last two reporting periods) April 12-March13 National Average 7.76 Highest National Score 30.95 Lowest National Score 1.68 Number of patient safety incidents that resulted in severe harm or death Unit 0 Reporting Periods (at least last two reporting periods) April12-Marcg 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 Unit Reporting Periods (at least last two reporting periods) April12-March 13 0.0 8.8 National Average 0.9 Highest National Score 2.9 Lowest National Score 0.0 The percentage of staff employed by The Somerfield Hospital during the reporting period, who would recommend The Somerfield Hospital as a provider of care to their family or friends. Unit Reporting Periods (at least last two reporting periods) 2013 80 National Average 64.58 Highest National Score 96.43 Lowest National Score 33.73 We are very proud of this score from the staff survey as staff satisfaction is important to The Somerfield Hospital. 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 Somerfield Hospital as a provider of care to their family or friends. Unit 80.09 Reporting Periods (at least last two reporting periods) June 13-Jan 14 National Average 66.23 Highest National Score 94.38 Lowest National Score 35.63 The Somerfield Hospital considers that this data is as described for the following reasons; patients have always been very happy with their care at The Somerfield Hospital and are very complimentary of all staff which is clearly demonstrated in the Quality Health questionnaire responses. We will continue to maintain this high quality care and will continue to value customer responses.