BMI Three Shires 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 Today that work has been superseded by the Private Hospitals Information Network which is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
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Hospital Information
BMI Three Shires Hospital is conveniently situated within the site of St Andrew’s Hospital in
Northampton and is part of BMI Healthcare. Britain’s leading provider of independent healthcare
with a nationwide network of hospitals and clinics. BMI Three Shires Hospital has 49 beds and
all rooms offer the privacy and comfort of en-suite facilities, satellite TV and telephone. The
hospital has three theatres, an endoscopy and minor procedures room and a four bed day care
unit. Our dedicated oncology unit treating a wide variety of cancers including Breast, Bowel,
Prostate, Ovarian, and Lung; was awarded the Macmillan MQEM award in March 2014.
The specialist expertise is supported by caring and professional medical staff, with dedicated
nursing teams and a Resident Medical Officer on duty 24 hours a day.
The amount of NHS work we carry out at The Three Shires is currently 23% of our admissions;
we accept patients from the Choose and Book network and are also involved in waiting time
initiatives, helping to reduce waiting times in the NHS by taking blocks of patients on spot
contracts.
In January 2014 we launched our clinical strategy which has six key core themes Care,
Compassion, Competences, Communication, Courage and Commitment.
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the
Health & Social Care Act 2008. BMI Three Shires Hospital is registered as a location for the
following regulated services:•
•
•
•
•
Treatment of disease, disorder and injury
Surgical procedures
Diagnostic and screening
Termination of Pregnancy
Family Planning
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The CQC carried out an unannounced inspection on 17th September 2013 and found
Standards of consent to care and treatment
Standards of care and welfare of people who use service
Standards of supporting workers
Standards of assessing and monitoring the quality of service
Standards of records
Three Shires 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 operationalized. There has been a continued development of the
Enhanced Recovery Programme to improve quality standards.
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.
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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, in liaison with the Infection Prevention and Control
Lead Three Shires Hospital
We have had: • Zero cases of MRSA bacteremia in the last year (NHS
1.17cases/100,000 bed days).
• Zero MSSA bacteremia cases /100,000 bed days
• Zero E.coli bacteremia cases/ 100,000 bed days
• Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
• SSI data is also collected and submitted to Public Health England for orthopedic surgical
procedures. Our rates of infection are;
o Hips = 0%
o Knees =0%
Infection control environmental audits were undertaken in all departments, using the IPS quality
improvement tool, results ranged from 87% to 96%. All areas audited had an action plan
compiled for any identified areas of non-compliance and action plans were completed by year
end.
A sharps disposal audit was also undertaken by Daniels Healthcare the providers of our sharps
disposal equipment. The result of this audit was favorable, compliance varying between 83%100%. Main areas of non-compliance were failure to use the temporary closure mechanism on
sharps boxes.
The Department of Health produced check lists called care bundles which identify best practice
which aid the prevention of healthcare associated infections in areas where there is an
increased risk if best practice is not followed. These care bundles are known
as “high impact interventions” and the following care bundles were audited: - Peripheral
intravenous cannula care bundle, Care bundle to prevent surgical site infection, Urinary catheter
care bundle and Central venous catheter care bundle.
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Results from these care bundle audits have been positive with good results. However there are
some areas where hand hygiene needs improvement and this is being addressed through
training and hand hygiene competency assessment.
Environmental cleanliness is also an important factor in infection prevention and our patients
rate the cleanliness of our facilities highly.
We have appointed a new lead Infection Prevention and Control Nurse who has brought a
wealth of knowledge and experience to the hospital. We have two assessors of Aseptic Non
Touch Technique (ANTT) which combined with an e-learning module are assessing all clinical
staff .
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1.2 Patient Led Assessment of the Care Environment (PLACE)
Last year’s PLACE assessment results were
•
•
•
•
Cleanliness - 99.71%
Food and Hydration -85.49%
Privacy, Dignity and wellbeing -80.77%
Condition appearance and maintenance -89.02%
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.
Following attendance of our DON at the NHS Commissioning Board PLACE training event in
February 2014, two PLACE assessors were recruited and a PLACE audit took place in March
2014.
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 results of this audit will not be available until later this year.
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 Three Shires Hospital. BMI Healthcare was awarded the
Best VTE Education Initiative Award category by Lifeblood in February 2013 and was 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 assess every patient who is admitted to our facility
and the results of our audit on this has shown – 100% of patients have a VTE assessment prior
to surgery
The Three Shires 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
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them. We continue to work with our Consultants and referrers in order to ensure that we have
as much data as possible, and are also in regular communication with NENE CCG regarding
any incidents of VTE post discharge that are reported through to them.
In the year, October 2012 to September 2013 The Three Shires Hospital reported zero incidents
of VTE. BMI The Three Shires VTE risk Assessment & Prophylaxis Audit conducted Quarterly
shows 100% compliance to the corporate Venous Thrombosis Prevention Policy
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 are 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 Three Shires Hospital.
Oxford Hip Score average
April 2012March2013
BMI Three
Shires
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
18.047
43.438
25.391
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 2012March 2013
BMI Three
Shires
Hospital
Q1
Q2
Health gain (Q2 - Q1 average)
18.964
37.182
18.218
18.893
34.902
16.01
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
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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
and 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
At Three Shires Hospital we have initiated an ERP working group and our current focus is:
•
Consultant education and support of the programme
• Ensuring that the planned length of patient stay is discussed at consultations
• Pre-operative warming of patients
• Pre-operative carb loading of patients
• GP referrers are kept informed of the ERP focus
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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.
During 2013/14 the figures for Three Shires Hospital are:
Unplanned readmissions within 31 days = 14
Unplanned return to theatre = 3
All of these variances are formally reported and discussed at the local Clinical Governance
Meetings and Medical Advisory Committee meetings to ensure that lessons learnt and changes
to practice are reviewed and appropriate changes made
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
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3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI
Three Shires 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.
At Three Shires Hospital we continually strive to improve our services and listen to the feedback
we have received over the past twelve months
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4.
CQUINS
Three Shires worked towards recording and achieving all National CQUINS and Local agreed
CQUINS.
•
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5.
National Clinical Audits
Three Shires Hospital was only eligible to participate in National Joint Registry audit and all joint
replacements are submitted to this. BMI hospitals data is from page 196 onwards in the latest
and including the following data.
•
•
•
•
•
6.
390 procedures performed by 11 orthopedic consultants
98% consent rate
96% linkability of proportion of records including a valid NHS number compared to
numbers on NJR
46% Male patients
Average age of 68.4
Research
No NHS patients were recruited to take part in research.
7.
Priorities for service development and improvement
•
•
•
•
Ongoing engagement with NHS Commissioners to enhance patient choice and service
delivery to NHS patients will be measured by agreed quality indicators
Maintain level of patient satisfaction regarding patient stay within our hospital, monthly
reports on questionnaires give trends of all aspects of care, accommodation.
environment. staff, consultants, food and information available to patients.
Audit compliance with Care bundles to ensure that these have been effectively
implemented, this will be measured by infection rates; these are measured monthly
through auditing patient records. Results are published on the CQUINS and safety
thermometer monthly for the Commissioners at the CCG.
PLACE audit has been undertaken and the report is expected in September 2014.
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8.
Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for the
(Three Shires Hospital) for the reporting period.
Unit
Value
and
Banding
Reporting Periods
(at least last two
reporting periods)
****
Data for this
due to be published
October 2014
National
Average
1.0006
Highest National
Score
1.1822
Lowest National
Score
0.6735
8.2 The Three Shires Hospital patient reported outcome measures scores for
(i) Groin hernia surgery
Unit
0.07
Reporting Periods
(at least last two
reporting periods)
April12- Mar13
National
Average
0.083
Highest National
Score
0.157
Lowest National
Score
0.014
The Three Shires Hospital considers that this data is as described for the following reasons
As a united team we ensure that the patient receives clear instruction and guidance on the
pathway they will be following. This structured approach commences from their first
appointment in Outpatients through to their discharge from the hospital and any community care
that may be required. The whole hospital team focuses on the patients care. They ensure that
the patient is provided with all information regarding their care pathway.
(ii) Varicose vein surgery- unable to report as no data
Unit
0
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
(iii) Hip replacement surgery
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National
Average
-8.738
Highest National
Score
8.172
Lowest National
Score
-15.918
Unit
43.438
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
National
Average
21.280
Highest National
Score
24.684
Lowest National
Score
17.214
The Three Shires Hospital considers that this data is as described due to• Nursing pre- assessment
• Physiotherapy pre-assessments
• Consultant involvement
• Patient education
(iv) Knee replacement surgery during the reporting period.
Unit
37.182
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
National
Average
15.99
Highest National
Score
20.37
Lowest National
Score
12.2
The Three Shires Hospital considers that this data is as described due to • Nursing pre- assessment
• Physiotherapy pre-assessments
• Consultant involvement
• Patient education
8.3 (i) The percentage of patients aged 3-14 readmitted to a hospital which forms part of the
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)
April12-Mar13
National
Average
11.45
Highest National
Score
Lowest National
Score
14.35
7.96
The Three Shires Hospital considers that this data is as described as we have not had any readmission of patients in this age range.
8.3.(ii)The percentage of patients aged 15 or over readmitted to a hospital which forms part of
the Three Shires Hospital within 28 days of being discharged from a hospital which forms part of
the hospital during the reporting period.
Unit
WĂŐĞͮϭϰ
Reporting Periods
(at least last two
National
Average
Highest National
Score
Lowest National
Score
reporting periods)
April12-Mar13
0
10.01
14.51
5.54
The Three Shires Hospital considers that this data is as described, there have been no readmissions of patients in this age range.
8.4 The Three Shires Hospital responsiveness to the personal needs of its patients during the
reporting period.
Unit
94.72
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
National
Average
Highest National
Score
68.1
84.4
Lowest National
Score
57.4
8.5 The percentage of patients who were admitted to Three Shires Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
100
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
National
Average
96
Highest National
Score
100
Lowest National
Score
79
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within the Three
Shires Hospital amongst patients aged 3 or over during the reporting period.
Unit
0
Reporting Periods
(at least last two
reporting periods)
April12- March13
National
Average
Highest National
Score
17.3
30.8
Lowest National
Score
0
8.7 The number and, where available, rate of patient safety incidents reported within the Three
Shires 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
55
Reporting Periods
(at least last two
reporting periods)
April 12- Mar13
National
Average
44.55
Highest National
Score
1,810
Rate of patient safety incidents reported (Incidents per 100 admissions)
WĂŐĞͮϭϱ
Lowest National
Score
0
Unit
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
6.25
National
Average
7.76
Highest National
Score
30.95
Number of patient safety incidents that resulted in severe harm or death
Unit
Reporting Periods
National
Highest National
(at least last two
Average
Score
reporting periods)
0
April12-Mar13
0.64
28
Lowest National
Score
1.68
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)
Apr12-Mar 13
0%
National
Average
0.9
Highest National
Score
2.9
Lowest National
Score
0.0
8.8 The percentage of staff employed by the Three Shires Hospital during the reporting period,
who would recommend the Three Shires Hospital as a provider of care to their family or friends.
Unit
Reporting Periods
(at least last two
reporting periods)
April12-Mar13
90%
National
Average
64.58
Highest National
Score
96.43
Lowest National
Score
33.73
9.
Non-Mandatory Quality Indicators
9.1
The percentage of patients who received care as inpatients during the reporting period,
who would recommend the Three Shires Hospital as a provider of care to their family or
friends.
Unit
87.45%
WĂŐĞͮϭϲ
Reporting Periods
(at least last two
reporting periods)
Jun13- Jan14
National
Average
Highest National
Score
Lowest National
Score
66.23
94.38
35.63