BMI Woodlands Hospital
Morton Park
Darlington
Quality Accounts 2013/2014
BMI Woodlands Hospital Quality Accounts
April 2013 to March 2014
Chief Executive’s Statement
Welcome to our Quality Accounts 2013/2014 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 Today that work has been superseded by the Private Hospitals Information Network which is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
BMI Woodlands Hospital
BMI Woodlands Hospital is set within a 5.25 acre site at Morton Park, Darlington. The hospital operates
37 beds comprising of 22 en-suite private rooms, a five bedded short stay ward, a six bedded short stay
ward and a 4 bedded high dependency level 2 unit that has been assessed and approved by the North
East Critical Care Network.
Our patient accommodation has been designed to be spacious, comfortable and bright; ensuring the
patients’ stay with us is as restful as possible. We have a rolling refurbishment programme with most of
the patient areas being redecorated throughout the last year.
Each private en-suite room is fitted with a remote controlled flat screen television with an inbuilt
entertainment system, a telephone and a nurse call system. The 5 and 6 bed wards each have a shared
TV and individual nurse call system and shared bathroom facilities. The wards areas have been assessed
by the Commissioners as compliant with the requirements to eliminate mixed sex accommodation.
Throughout the patient areas there is free Wi-Fi installed for patient and visitor use also there is free
parking available at the hospital.
The hospital has a wide bore fixed MRI scanner which can accommodate patients who have
claustrophobia and a high BMI, we offer a mobile CT scanning service, have a fully equipped gymnasium
and an endoscopy unit in addition to the two laminar flow theatres.
We offer an extensive range of inpatient/ daycase /short stay and outpatient services, supported by over
150 experienced Consultants.
We provide the very highest standards of modern medical care and we are BUPA accredited for our
breast care services.
All the staff at BMI Woodlands Hospital are committed to ensuring the patients are confident and
comfortable with every aspect of their visit. The Director of Nursing is on hand to address any concerns
patients / visitors may have and there are Resident Medical Officers are available 24 hours a day.
NHS Activity
NHS activity is undertaken at BMI Woodlands Hospital and is currently around 50% of the total volume of
work. There is an agreed ‘Standard Acute Contract’ with the local Clinical Commissioning Groups (CCGs)
and services such as Orthopaedics, Gynaecology, Urology, General Surgery, Ear Nose and Throat
(ENT), Ophthalmology and Spinal Surgery all form part of this contract. The services form part of the
Choose and Book system and BMI Woodlands Hospital is accountable for the delivery of the quality,
financial and waiting time targets that all other NHS providers have to achieve. The NHS patients are
surveyed to ascertain their satisfaction with the quality of the services and the feedback is consistently
very high.
Care Quality Commission (CQC) Registration
BMI Healthcare is registered as a provider with the Care Quality Commission (CQC) under the Health &
Social Care Act 2008. BMI Woodlands 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 24 February 2014 and found that the BMI
Woodlands Hospital is fully compliant with the following standards:•
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 management
BMI Woodlands 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 Boards’ monitor and analyse trends and ensure that the quality
improvements are operationalised.
At a 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 at BMI Woodlands Hospital.
BMI Woodlands Hospital has had: •
Zero cases of MRSA bacteraemia in the last year (NHS
1.17cases/100,000 bed days)
•
Zero cases of MSSA bacteraemia cases /100,000 bed days
•
Zero cases of E-coli bacteraemia cases/ 100,000 bed days
•
Zero cases of hospital apportioned Clostridium difficile in the last 12 months.
Surgical Site Infection (SSI) data is also collected and submitted to Public Health England for orthopaedic
surgical procedures. Our rates of infection are:•
•
Zero for Hips
Zero for Knees
A full hospital Infection Control and Prevention Programme is in place at BMI Woodlands Hospital which
includes monthly audits of high impact care bundles to identify compliance with infection control
processes covering:•
•
•
Surgical Site Infection
Peripheral Lines
Central Lines
•
•
Urinary Catheter Care
Aseptic non-touch technique
Audit reports demonstrate full compliance with the above care bundle pathways on a monthly basis. Hand
hygiene audits are also carried out monthly in all areas to reinforce the importance of this in maintaining
an infection free environment.
Environmental cleanliness is also an important factor in infection prevention and our patients rate the
cleanliness of our facilities highly as the charts illustrate below:-
1.2 Patient Led Assessment of the Care Environment (PLACE)
A clean environment is the foundation for lower infection rates, whilst good food promotes recovery and
improves the patient experience. High standards of privacy and dignity and good maintenance and décor
support a safe and comfortable stay for the patients cared for at BMI Woodlands Hospital.
Staff at BMI Woodlands Hospital believe patients’ should be cared for with compassion and dignity in a
clean, safe environment. Where standards fall short, the patient and their family should be able to draw it
to the attention of managers and hold the service to account.
In 2013 PLACE, which is the new system for assessing the quality of the patient environment, replacing
the old Patient Environment Action Team (PEAT) inspections was introduced. PLACE assessments
provide motivation for improvement by providing a clear message, directly from patients, about how the
environment or services might be enhanced.
The assessments involve patients’ and staff who assess the hospital and how the environment supports
patients’ 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 show how hospitals are performing nationally and locally. The results for BMI Woodlands
Hospital across the four categories assessed for 2013 are as follows:•
Cleanliness
99.7%
•
Food and hydration
94.4%
•
Privacy , dignity and wellbeing
97.37%
•
Condition appearance and maintenance
97.33%
BMI Woodlands hospital achieved an overall score of 388.82% out of a possible score of 400%
demonstrating the commitment of the hospital to improving all aspects of the patient experience.
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 Woodlands 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.
BMI Healthcare see this as an important initiative to further assure patient safety and care. Audits are
performed to ensure compliance with the requirements. VTE risk assessments are performed on every
patient who is admitted to BMI Woodlands Hospital and the results of the audit on this has shown 100%
compliance with this practice. BMI Woodlands Hospital intends to continue risk assessing every patient in
relation to this indicator to ensure that patients are reassured by our safety measures.
BMI Woodlands 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 GP or other hospitals for diagnosis and/or treatment of VTE post discharge from the
Hospital. As such staff at BMI Woodlands Hospital may not be made aware of them.
BMI Woodlands Hospital continues to work with Consultants and referrers in order to ensure that they
have as much data as possible. The chart overleaf shows that BMI Woodlands Hospital had a rate of
0.0170 DVT rate per 100 admissions in 2013/14, demonstrating the extremely low rate of DVT incidents
experienced by patients.
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2. Effectiveness
2.1 Patient reported Outcomes (PROMS)
Patient Reported Outcome Measures (PROMs) is a Department of Health led program which is a means
of collecting information on the effectiveness of care delivered to NHS patients’ as perceived by the
patients’ themselves.
For the current reporting period, the tables below and overleaf demonstrate the health gain between
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing hip
replacement and knee replacement at BMI Woodlands Hospital.
Oxford Hip Score average
April 12
Mar 13
–
BMI
Woodlands
Hospital
Q1
Q2
Health gain
periods
21.306
40.806
19.5
17.907
39.224
21.317
between
reporting
England
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
Woodlands
Hospital
Q1
Q2
Health gain
periods
19.76
36.319
16.551
18.893
34.902
16.01
between
reporting
England
Copyright © 2013, The Health and Social Care Information Centre. All Rights Reserved.
The data shows that BMI Woodlands Hospital are comparative with the national average health gain for
both the Oxford Hip and Knee Score, however, the data returns are below the number required for the
results to be statistically significant, due to the lower volume of cases undertaken in comparison to NHS
Trust providers.
2.2 Enhanced Recovery Programme (ERP)
The ERP is about improving patient outcomes and speeding up a patients’ 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 co-morbidities,
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 vast majority of patients that attend for surgery at BMI Woodlands Hospital follow an enhanced
recovery pathway. This involves using thorough pre-operative assessment and patient management, the
use of regional blocks for pain control and early mobilisation post -surgery.
The average length of stay (LOS) post total hip replacement is currently 2.3 days which, is well below the
NHS national average LOS and which demonstrates an improvement upon BMI Woodlands Hospital
average LOS in 2012/13, which was 2.8 days.
Similarly, the average length of stay (LOS) for a total knee replacement at BMI Woodlands Hospital is
currently 2.4 days which is well below the NHS national average and which is an improvement upon the
LOS reported last year for BMI Woodlands Hospital which was 3.5 days.
The chart below illustrates the consistent improvement which BMI Woodlands Hospital has achieved in
reducing the average LOS across all surgical procedures. For 2013 the overall average LOS was 2.15
days.
Introducing the ERP has assisted us to achieve these outcomes and work is ongoing to continually
improve on current outcomes across all specialties
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.
The chart overleaf shows the total average unplanned readmission rates per 100 discharges for the past
5 years. As can be seen unplanned readmissions to BMI Woodlands Hospital are very low with the
average rate for 2013 being 0.23 per 100 discharges. Year to date (2014) there is a slight increase on
last year showing an average rate of 0.29 per 100 discharges however, the hospital has seen a significant
increase in activity volumes and complexity in case mix from the latter part of 2013 into 2014.
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BMI Woodlands Hospital has a very low rate of unplanned returns to theatre as demonstrated in the chart
below. The average for 2013 was 0.27 per 100 theatre cases.
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Year to date (2014) the average unplanned return to theatre rate is 0.11 per 100 theatre cases. This may
be reflective of a more complex case mix of surgery being undertaken in the hospital this year with the
official opening of the High Dependency beds.
The hospital Clinical Governance Board monitors returns to theatre and each case is analysed to
ascertain whether there are any improvements that could be made or whether preventative action could
be taken. None of the cases returned to theatre have required us to make any significant changes to
practice.
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 and sent to the
hospital on a monthly basis.
The patient satisfaction questionnaires ask patients specific questions around all areas of their care and
treatment and covers accommodation, facilities, nursing staff, consultant staff, theatre staff, physiotherapy
services, radiology services, food quality, pain management, information
Overall Rating of Quality of Care
The questionnaire also asks how the patient rated their overall quality of care (which takes into account
all areas of their care and treatment as outline above). This is measured across two categories; very good
and excellence. The table below shows the overall rating of quality of care provided by BMI Woodlands
Hospital during the period 1 April 2013 to 31 March 2014 and is ranked in two categores - excellent or
very good. The percentage of respondents who rated the hospital as excellent in quality care provision is
86.6% and the percentage of respondents who rated the hospital as very good is 98.9%.
The overall rating of quality of care response for 2012 was 83.8% for excellence and 96.7% for very good.
Comparing the last two years sets of data in both categories of quality of care outlined in the charts
below, demonstrates that there has been an increase in respondents who would rate the care as
excellent by 2.8% and an increase of respondents who would rate the care as very good by 2.2%, despite
an increase in activity volumes and case mix complexity which the hospital has experienced in the last
year.
Overall Rating of Quality of Care 2013
Overall Rating of Quality of Care 2012
Looking at individual indicators of quality of care provided by BMI Woodlands Hospital, the chart below
illustrates patient satisfaction scores across ten quality indicators surveyed for both ‘excellence’ and ‘very
good’ for a full year in 2012 and 2013:
Comparison of Patient Satisfaction Quality Indicators 2012 and 2013
Quality
2012 %
2013 %
Variance
2012 %
2013 %
Category
Excellence Excellence
Very
Very
Good
Good
Arrival
70.4
70.5
0.1
93.1
95.2
Process
Consultant
88.8
89.9
1.1
98.3
99.2
Anaesthetist
5.6
81.3
86.9
97.1
97.8
Nursing Care
2.8
80.0
82.8
95.7
97.8
Pain
3.7
94.6
95.0
71.9
75.6
Management
Involved
in 89.6
90.6
1.0
98.9
99.1
Care
Decisions
97.7
0.3
99.6
99.6
Respect
& 97.4
Dignity
Accomodation 74.2
74.9
0.7
93.9
95.9
Catering
68.7
68.6
-0.1
92.8
92.3
Discharge
68.4
68.6
0.2
90.9
91.7
Process
Variance
2.1
0.9
0.7
2.1
0.4
0.2
0
2.0
-0.5
0.8
The above scores demonstrate an overall increase in quality of care for 9 out of 10 indicators, with
catering remaining relatively static for both years. The most marked increases are in satisfaction scores
associated with the Anaesthetist in the excellence category, an increase in satisfaction with pain
management in the excellence category and an increase in the very good category for the arrival process
and accomodation. Patient satisfaction with overall nursing care in both of the categories has seen a
healthy increase this year. This increase in patient satisfaction scores across these indicators
demonstrates the BMI Woodlands Hospitals drive to constantly improve the quality of care offered to all
patients who are treated here.
3.2 Complaints
In addition to providing all patients with an opportunity to complete a satisfaction survey BMI Woodlands
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 stage 2.
The chart above illustrates the number of written complaints per 100 admissions to BMI Woodlands
Hospital for the past 5 years. As can be seen the complaint rate is very low currently standing at 0.35 per
100 admissions year to date. The average rate per 100 admissions in 2013 was 0.64 which was an
increase from the 2012 position but may be associated with an increase in activity volumes across all
departments and an increase in case mix complexity on the ward and in theatres.
The main themes of complaints received by BMI Woodlands Hospital in 2013 includes:•
•
•
•
Dissatisfaction with staff attitude
Patient dissatisfaction with elements of their care
Patient unhappiness with outcome of surgery
Dissatisfaction with administrative and billing services
Of all of the complaints received only 1 complaint was escalated to stage 2 of the complaints process. All
of the others were resolved at stage 1 at hospital level.
The standard times for responding to complaints within BMI was 100% achieved in 2013. Management
at BMI Woodlands Hospital take complaints very seriously and always review how practices can be
changed or improved where a patient has had cause for complaint, in order to reduce patient
dissatisfaction with our services.
4. CQUINS
The Standard Acute Contract that BMI Woodlands Hospital holds formally with local Primary Care Trusts
(PCTs) and now with the CCGs, includes participation in the NHS Commissioning for Quality and
Innovation Scheme (CQUIN) on an annual basis.
This involves staff working with Commissioners to deliver the national CQUIN initiatives set by the
Department of Health and to identify local CQUIN initiatives which aim to improve the quality of care
delivered to patients at hospital level. Last year BMI Woodlands Hospital was commissioned to deliver
NHS work via the Standard Acute Contract for all commissioners across County Durham and Darlington,
Tees Valley and North Yorkshire. Each required us to deliver the National NHS CQUIN initiatives which
were:1. Improve responsiveness to personal needs of patients - Implementation of the Friends &
family test – this required BMI Woodlands Hospital to survey patients with the aim of asking whether
they would recommend the hospital to family and friends.
This was successfully implemented by adding the question to our patient satisfaction questionnaires
although there has been a gradual increase across the year the hospitals percentage returns, just fell
short of the 20% threshold required. Focus continues with regard to improving the return rate.
2. Implementation of the National NHS Safety Thermometer
2.1. Safety Thermometer survey data for all appropriate patients
This required BMI Woodlands Hospital to submit data on all NHS patients in hospital on a defined
day in the month reporting on instances of: pressure sores; Urinary Tract Infections (UTI’s) in
patients with catheters; falls and VTE.
CQUIN fully achieved.
2.2. Reduction in Urinary Tract Infections (UTIs)
This indicator required that BMI Woodlands hospital report on the number of patients who had
catheters post-surgery and whether a UTI had been detected. A total of 106 patients had catheters
in post-operatively and no UTI’s were reported
CQUIN fully achieved.
2.3. Surgical Care Bundle Audits – Catheters
For this indicator BMI Woodlands Hospital were required to audit whether cases were compliant
with best practice. All catheters audited (106) were found to be compliant against best practice for
catheter care bundles.
CQUIN was fully achieved.
3.
Reducing
avoidable
death,
disability
and
chronic
ill
health
from
VTE
3.1 VTE Risk Assessment
This indicator required us to identify the percentage of adult patients who have had a VTE risk
assessment on admission to the hospital using the clinical criteria of the national tool.
CQUIN fully achieved.
3.2 VTE Route Cause Analysis (RCA)
If any hospital associated VTE’s had been identified during the year, this indicator required them
to undertake a RCA on each case. There were no episodes of hospital associated VTE’s identified
at BMI Woodlands Hospital during 2013/14/
Therefore, this was not applicable.
Local CQUIN indicators
Local QUIN initiatives that were agreed with Commissioners included:
•
Every Health Contact Counts - This required BMI Woodlands Hospital to identify one health
related contact with patients’ to try to improve their health and wellbeing.
•
BMI Woodlands Hospital focused upon smoking cessation with the aim of identifying patients
who were smoking at their pre-operative visit prior to planned surgery and giving smoking
cessation advice and literature to encourage them to stop smoking prior to surgery and thereafter.
•
Between April 2013 and March 2014 a total of 145 patients declared they were smokers therefore
all were offered ‘Quit Smoking’ packs. Out of the 145 patients 51 of them declined the information
or stated that they were already in the process of stopping smoking.
This local CQUIN was fully delivered demonstrating our commitment to deliver the highest standards of
care possible for our patients.
CQUIN 2014/15
As well as the National NHS CQUIN Initiatives, BMI Woodlands Hospital has agreed local CQUIN
initiatives with commissioners this year to include:
1.
2.
3.
Improvements made as a result of patient experience/feedback
Health contacts in relation to smoking cessation and alcohol use
Improving patient experience focusing on staff attitude and communication
5. National Clinical Audits
BMI Woodlands Hospital was only eligible to participate in the National Joint Registry audit. Therefore all
appropriate data for patients who had a joint replacement was submitted.
6. Research
No NHS patients were recruited to take part in research.
7. Priorities for service development and improvement
This year BMI Woodlands Hospital intends to improve and develop its services further with particular
focus on the following:
1.
2.
3.
4.
Development of a Spinal Centre of Excellence
Development and expansion of Musculo Skeletal Service (MSK)
Expansion of the Endoscopy unit
Expansion of the overall hospital capacity
8. Mandatory Quality Indicators
8.1 The value and banding of the summary hospital-level mortality indicator (SHMI) for BMI Woodlands
Hospital reporting period.
Unit Reporting Periods
(at
least
last
reporting periods)
0
Oct 11 – Jun 13
National
two Average
1.0006
Highest
Score
1.1822
National Lowest
Score
National
0.6735
BMI Woodlands Hospital has had no perioperative or post-operative deaths and therefore, is below the
national average for the SHMI. The hospital intends to continue to implement best practices in relation to
quality and clinical effectiveness to maintain this position.
8.2 BMI Woodlands Hospital Patient Reported Outcome Measures (PROMS) scores for ;
(i) Groin hernia surgery
Unit
0.047
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
0.083
Highest
Score
0.157
National Lowest
Score
National
0.014
BMI Woodlands Hospital is slightly below the national average for health gain following groin hernia
surgery but is significantly ahead of the lowest national reported score. It should be noted however, that
due to the very low numbers carried out at the hospital the data may not be statistically significant.
(ii) Varicose vein surgery
Unit
NA
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
-8.738
Highest
Score
8.172
National Lowest
Score
-15.918
National
BMI Woodlands Hospital has moved away from surgical intervention for varicose veins and most are now
managed by VNUS which is seen as best practice in the management of varicose veins. This is an
ablation technique performed under ultrasound control and is not monitored under the auspice of PROMs.
(iii) Hip replacement surgery
Unit
21.33
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
21.280
Highest
Score
24.684
National Lowest
Score
National
17.214
BMI Woodlands Hospital is above the national average for health gain post hip replacement surgery.
This is possibly due to the Enhanced Recovery Pathway that is followed by most of the surgeons
operating from the hospital and the multi-disciplinary team working to achieve best practice. The intention
is to push forward with this initiative to include all surgeons working at the hospital in order to move closer
to the highest national average score.
(iv) Knee replacement surgery
Unit
17.07
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
15.99
Highest
Score
20.37
National Lowest
Score
National
12.2
BMI Woodlands Hospital is significantly above the national average for health gain post knee replacement
surgery. As with the comments above regarding hip replacement this is possibly due to the Enhanced
Recovery Pathway and the intention to push forward the initiative is the same as above.
8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of the BMI
Woodlands Hospital within 28 days of being discharged during the reporting period.
Unit
NA
Reporting Periods
(at least last
reporting periods)
Apr 11 - Mar 12
National
two Average
11.45
Highest
Score
14.35
National Lowest
Score
National
7.96
BMI Woodlands Hospital does not admit patients aged 0-14 years of age and therefore this is not
applicable.
8.3.(ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of the BMI
Woodlands Hospital within 28 days of being discharged from a hospital during the reporting period.
Unit
0.23
Reporting Periods
(at least last
reporting periods)
Apr 11 – Mar 12
National
two Average
10.01
Highest
Score
14.51
National Lowest
Score
National
5.54
The number of readmissions to BMI Woodlands Hospital during 2013 was extremely low with the actual
percentage being 0.23%. This equates to 11 patients in 4772 admissions to the hospital during this time
period. This is significantly below the national average and the lowest national score as outlined in the
table above.
Readmissions often occur due to complications of surgery. Staff at BMI Woodlands Hospital encourage
patients to come back to the hospital so that we can treat them as efficiently and effectively as possible.
Each case of readmission is discussed at the BMI Woodlands Hospital Clinical Governance meeting and
any change to practice is implemented as required. This year staff have implemented a process which
involves a telephone call to all of the patients’ who have had surgery in order to give advice and
reassurance. This helps the staff to intervene and assist with any problems at the earliest time and may
assist further in reducing readmission rates going forward this year.
8.4 BMI Woodlands responsiveness to the personal needs of its patients during the reporting period.
Unit
94.23
Reporting Periods
(at least last
reporting periods)
2012-2013
National
two Average
68.1
Highest
Score
84.4
National Lowest
Score
National
57.4
BMI Woodlands Hospital’s responsiveness to the personal needs of its patients scores very highly and far
surpasses the national average and the highest national score. Staff consider this to be the case due to
their drive to consistently improve the patient experience.
The Senior Management Team intend to continue to improve this by developing a ‘Patient Environment
and Improvement Group’ (PEIG) which will have patient representation and members from the local
HealthWatch which will seek to make improvements in line with patient feedback and observations.
8.5 The percentage of patients who were admitted to BMI Woodlands Hospital and who were risk
assessed for venous thromboembolism during the reporting period.
Unit
100%
Reporting Periods
(at least last
reporting periods)
Apr 13 – Jan 14
National
two Average
96
Highest
Score
100
National Lowest
Score
National
79
BMI Woodlands Hospital has an excellent track record for this indicator, surpassing the national average
and equaling the highest national score. The hospital staff will continue to implement best practice in VTE
management in order to maintain this position.
8.6 The rate per 100,000 bed days of cases of C difficile infection reported within BMI Woodlands
Hospital amongst patients aged 2 or over during the reporting period.
Unit
0
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
17.3
Highest
Score
30.8
National Lowest
Score
National
0
BMI Woodlands Hospital has had no episodes of Clostridium Difficile reported for the period 2012 -2013
and considers that this data is as described because of the strong focus upon infection prevention and
control (IPC) within the hospital. Staff will continue with the IPC programme and implementation of best
practice to maintain this excellent standard.
8.7 The number and, where available, rate of patient safety incidents reported within BMI Woodlands
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
125
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
44.55
Highest
Score
1,810
National Lowest
Score
National
0
Rate of patient safety incidents reported (Incidents per 100 Admissions)
Unit
2.61
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
7.76
Highest
Score
30.95
National Lowest
Score
National
1.68
Number of patient safety incidents that resulted in severe harm or death
Unit
0
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
0.64
Highest
Score
28
National Lowest
Score
National
0
Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100
Admissions)
Unit
0
Reporting Periods
(at least last
reporting periods)
Apr 12 – Mar 13
National
two Average
0.9
Highest
Score
2.9
National Lowest
Score
National
0.0
BMI Woodlands Hospital reports all clinical incidents and patient safety related incidents. The number
reported above includes a high proportion of patients who were planned as day cases and for clinical
reasons stayed overnight, which is classed as an adverse outcome on the BMI Sentinel reporting system.
There have been two incidents which were classed as serious untoward incidents but no incidents which
resulted in severe harm to a patient or death.
The hospital has put systems and processes in place to prevent the two incidents from occurring again
and we work very hard to ensure that patient safety is our highest priority as a hospital.
8.8 The percentage of staff employed by the BMI Woodlands Hospital during the reporting period, who
would recommend the hospital as a provider of care to their family or friends.
Unit
99
Reporting Periods
(at least last
reporting periods)
2013
National
two Average
64.58
Highest
Score
96.43
National Lowest
Score
National
33.73
BMI Woodlands Hospital scores well above the national average for this indicator and above the highest
national score recorded, demonstrating the faith that employees have in the care that is delivered within
the hospital. Many staff and family members have been treated successfully at BMI Woodlands Hospital
in recent years.
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 BMI Woodlands Hospital as a provider of care to their family
or friends.
Unit
88
Reporting Periods
(at least last
reporting periods)
Jun 13 – Jan 14
National
two Average
66.23
Highest
Score
94.38
National Lowest
Score
National
35.63
The percentage of patients who would recommend BMI Woodlands Hospital to family and friends is
currently 88% which is significantly higher than the national average, however the response rate for the
patient satisfaction survey is fairly low and the score is reflective of this.
We intend to improve this score next year by endeavoring to increase the response rates to the question
on our survey and to identify other methods of acquiring feedback on this important indicator next year.
This concludes the quality accounts for BMI Woodlands Hospital for 2013/ 2014 if you would like to
discuss any aspect of this report please do not hesitate to contact Debbie Dobbs (Executive Director) or
Jill Neasham (Director of Nursing).