BMI The Harbour Hospital Quality Accounts April ... - BMI Healthcare
BMI The Harbour Hospital Quality Accounts April ... - BMI Healthcare
BMI The Harbour Hospital Quality Accounts April ... - BMI Healthcare
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>BMI</strong> <strong>The</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong><br />
<strong>April</strong> 2011 to March 2012<br />
Chief Executive’s Statement<br />
Welcome to our <strong>Quality</strong> <strong>Accounts</strong> 2012. This is the third set of <strong>BMI</strong><br />
<strong>Healthcare</strong> <strong>Quality</strong> <strong>Accounts</strong> and my first as Chief Executive, and I<br />
am pleased to see their development as a really useful tool to assess<br />
how we at <strong>BMI</strong> are performing against a broad range of quality<br />
criteria. <strong>BMI</strong> <strong>Healthcare</strong> focuses on clinical excellence through<br />
quality of service and efficiency. Success in these areas translates<br />
into a consistently good patient experience and the right environment<br />
to enable consultants to provide their best care.<br />
Since they were first introduced three years ago, <strong>Quality</strong> <strong>Accounts</strong><br />
have developed amid significant changes in the national health economy. <strong>The</strong> passing into law<br />
of the Health and Social Care Act earlier this year heralds more opportunities for <strong>BMI</strong><br />
<strong>Healthcare</strong> to contribute towards increased choice for patients, based on transparent quality<br />
information. We are pleased that the Department of Health and Monitor have recently reiterated<br />
that <strong>Quality</strong> <strong>Accounts</strong> are an increasingly important tool for strengthening accountability for<br />
quality within provider organisations.<br />
<strong>The</strong> recently initiated Competition Commission review of private healthcare is likely to focus on<br />
whether there is a lack of comparable quality data, thus impairing effective decision-making by<br />
patients. <strong>BMI</strong> <strong>Healthcare</strong> is committed to producing high quality group and hospital-level data<br />
that allows patients and referring clinicians to compare different facilities and make informed<br />
choices and we are keen that the Hellenic project, which is working across the private<br />
healthcare sector, is able to generate standardised quality measures and indicators for private<br />
providers as soon as possible. Patients and clinicians deserve - and need - access to<br />
standardised information and whilst there are some very useful initiatives, such as that<br />
published by the National Joint Registry, a national scheme to help patients make informed<br />
choices of providers is essential. We will over the coming year therefore be increasing our<br />
financial commitment to Hellenic to play our part in enabling this.<br />
In the last financial year <strong>BMI</strong> invested almost £44m to improve and extend our clinical services,<br />
improve hospital infrastructure and enable better business processes, as part of a continuing<br />
commitment to improve quality of facilities and services. <strong>The</strong>se include major upgrades in some<br />
of our hospital’s theatre complexes, ongoing upgrades in our MRI and CT scanners and the<br />
start of work to replace our existing patient administration system.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
1
We believe that all providers of health services should strive to deliver the best quality –<br />
assessed across the domains of patient safety; procedural effectiveness; and patient<br />
experience. It is crucial that patients and clinicians should have easy access to this information<br />
in order to make informed choices about where and how they want to be treated.<br />
I am proud of the progress shown in <strong>BMI</strong>’s <strong>Quality</strong> <strong>Accounts</strong>. <strong>The</strong> information available has<br />
been reviewed by the Clinical Governance Board and I declare that as far as I am aware the<br />
information contained in these is accurate. I am fully aware of all of the hard work by our staff<br />
that lies behind the improvements reflected in the numbers shown. I pass my thanks to all staff<br />
for their involvement in this.<br />
Stephen Collier, Chief Executive Officer<br />
<strong>BMI</strong> <strong>The</strong> <strong>Harbour</strong> <strong>Hospital</strong> in Poole,<br />
Dorset is part of <strong>BMI</strong> <strong>Healthcare</strong>, Britain's<br />
leading provider of independent healthcare<br />
with a nationwide network of hospitals &<br />
clinics. <strong>The</strong> <strong>Hospital</strong> has 37 beds with all<br />
rooms offering the privacy and comfort of<br />
en-suite facilities, broadband, TV and<br />
telephone. <strong>The</strong> hospital has three theatres,<br />
including an endoscopy suite and high<br />
dependency rooms.<br />
1. Regulatory landscape<br />
<strong>BMI</strong> <strong>Healthcare</strong> are registered as a provider with the Care <strong>Quality</strong> Commission (CQC) under the<br />
Health & Social Care Act 2008. <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> is registered as a location for the following<br />
regulated services:-<br />
• Treatment of disease, disorder and injury<br />
• Surgical procedures<br />
• Diagnostic and screening<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
2
<strong>The</strong> focus is on healthcare outcomes rather than process and the key requirement is to provide<br />
evidence of these and not just to produce the “policy”. <strong>The</strong> Group <strong>Quality</strong> & Risk Team<br />
continues to provide guidance and support to ensure compliance with all regulatory standards.<br />
Six-monthly unannounced provider visits to all sites help us to monitor performance and to<br />
address any issues.<br />
<strong>The</strong> CQC have not had cause to take any enforcement action against <strong>Harbour</strong> <strong>Hospital</strong> and the<br />
hospital has not been the subject of any special reviews or investigations. <strong>The</strong> CQC carried out<br />
an unannounced inspection on 15 th December 2012 and found the hospital to be compliant with<br />
all standards assessed. .<br />
Standards of treating people with respect and involving them in their care<br />
Standards of providing care, treatment & support which meets people's needs<br />
Standards of caring for people safely & protecting them from harm<br />
Standards of staffing<br />
Standards of management<br />
2. Governance<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> has a local framework through which clinical effectiveness, clinical<br />
incidents and clinical quality is monitored and analysed. Where appropriate, action is taken to<br />
continuously improve the quality of care. This is through the work of a multidisciplinary group<br />
and the Medical Advisory Committee.<br />
At corporate level the Clinical Governance Board has an overview and ensures that there is<br />
corporate learning and quality improvement.<br />
<strong>The</strong>re has been ongoing focus on robust reporting of all incidents, near misses and outcomes,<br />
to ensure availability of information for effective clinical governance with implementation of<br />
appropriate actions to prevent recurrences in order to improve quality and safety for patients,<br />
visitors and staff.<br />
<strong>The</strong>re are external reporting requirements for CQC, Health Protection Agency, PCTs and<br />
Insurers. <strong>The</strong>re has also been ongoing progress on the Hellenic project, which is a sector wide<br />
quality indicator reporting project which will provide the opportunity for independent providers to<br />
report as a sector and to benchmark against each other and the NHS in a number of key<br />
indicators of quality. Submission processes have been fine-tuned and the focus now is on<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
3
ensuring consistent quality of the data. We continue to report under the domains of safety,<br />
effectiveness and patient experience<br />
3. Safety<br />
3.1 Infection prevention and control<br />
<strong>The</strong> focus on infection prevention and control continues under<br />
the leadership of the Group Head of Infection Prevention and<br />
Control, in liaison with the link nurse in <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong>.<br />
Due to healthcare media coverage of infections, one of the most<br />
frequently asked question from patients is: “How likely is it that I<br />
will get an infection in your hospital?” Two infection rates<br />
published by the Health Protection Agency are those of MRSA<br />
bacteraemias and Clostridium difficile, and with these results we<br />
are able to reassure them that due to effective pre-admission<br />
assessment and the high standard of clinical care delivered<br />
during and after their surgery, the risk is very low.<br />
At <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> there have been zero cases of hospital apportioned Clostridium difficile<br />
(20 cases/100,000 bed days in NHS hospitals) over the last year and zero cases of MRSA<br />
bacteraemias since the independent sector began to report to HPA in 2008. This is compared to<br />
1.1 cases/100,000 bed days in NHS hospitals for the period <strong>April</strong> 2010 to December 2011<br />
(latest data published).<br />
Environmental cleanliness is also an important factor in infection prevention and our patients<br />
rate the cleanliness of our facilities highly.<br />
Care Bundles were introduced in the second half of the reporting period and monitoring results<br />
of audit and monitoring will be reported in next year’s <strong>Quality</strong> <strong>Accounts</strong>.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
4
3.2 Patient Environment Action Team Assessments (PEAT) 2012<br />
PEAT is an annual assessment of inpatient healthcare sites in England that have more than 10<br />
beds. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of<br />
patient care including environment, food, privacy and dignity.<br />
<strong>The</strong> assessment results help to highlight areas for improvement and share best practice across<br />
healthcare organisations in England.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> has improved their scores for Catering but the score for Environment has<br />
decreased and will be the focus for quality improvement over the year.<br />
<strong>BMI</strong><br />
Year Environment Food Privacy & Dignity<br />
2012 Acceptable Good Good<br />
2011 Good Acceptable Excellent<br />
3.3 Venous Thrombo-embolism (VTE)<br />
<strong>BMI</strong> <strong>Healthcare</strong>, has recently been awarded VTE Exemplar Centre status by the Department of<br />
Health across its whole network of hospitals including, <strong>The</strong> <strong>Harbour</strong> <strong>Hospital</strong>. We see this as an<br />
important initiative to further assure patient safety and care. To deliver the initiative <strong>BMI</strong><br />
<strong>Healthcare</strong> established a National Thrombosis Team, chaired by the Group Chief Pharmacist.<br />
<strong>The</strong> Team had the responsibility of implementing the Venous Thrombosis Prevention Policy<br />
which was launched alongside a new risk assessment tool, patient information leaflets,<br />
prophylaxis (prevention) protocols, training packages and regular audits to ensure ongoing<br />
compliance. All patients undergo an appropriate VTE risk assessment and decisions are made<br />
on appropriate prophylaxis.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> reports all VTE and pulmonary embolus (PE) through the corporate<br />
clinical incident reporting system. It is acknowledged that the challenge is receiving information<br />
for patients who may return to their GPs or other hospitals for diagnosis and/or treatment of VTE<br />
post discharge from the <strong>Hospital</strong>. As such we may not be made aware of them. We continue to<br />
work with our Consultants and referrers in order to ensure that we have as much data as<br />
possible.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> had and incidence of 0.02% of DVTs per 100 admissions and no reported<br />
PEs in this reporting period.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
5
4. Effectiveness<br />
4.1 Patient reported Outcomes (PROMS)<br />
Patient Reported Outcome Measures (PROMs) are a means of collecting information on the<br />
effectiveness of care delivered to NHS patients as perceived by the patients themselves.<br />
PROMs is a Department of Health led programme supported by a number of key partner<br />
organisations, including <strong>The</strong> NHS Information Centre for health and social care. Eligible<br />
procedures are hip and knee replacement, inguinal hernia repair, varicose vein surgery for NHS<br />
patients who consent to participate and complete questionnaires. <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> has<br />
participated in the PROMS programme but has not carried out any hip or knee replacements,<br />
varicose vein surgery for NHS patients.<br />
For the current reporting period, the tables below demonstrate that the health gain between<br />
Questionnaire 1 (pre-operative) and Questionnaire 2 (post–operative) for patients undergoing<br />
Inguinal hernia repair is better than the average for England.<br />
2011/2012<br />
Inguinal Hernia repair<br />
Q1 Q2 Health gain (Q2 - Q1 average)<br />
<strong>Harbour</strong><br />
<strong>Hospital</strong><br />
England<br />
80.429 82.429 2.000<br />
79.699 79.443 -0.256<br />
Copyright © 2011 Re-used with the permission of <strong>The</strong> Health and Social Care Information Centre. All rights<br />
reserved.'<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
6
4.2 Unplanned Readmissions within 31 days and unplanned returns to theatre.<br />
Unplanned readmissions and unplanned returns to theatre are normally due to a clinical<br />
complication related to the original surgery. <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> has had a decrease in the<br />
indicators over the lat year.<br />
.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
7
5. Patient experience<br />
5.1 Patient satisfaction<br />
<strong>BMI</strong> <strong>Healthcare</strong> is committed to providing the highest levels of quality of care to all of our<br />
patients. We continually monitor how we are performing by asking patients to complete a patient<br />
satisfaction questionnaire. Patient satisfaction surveys are administered by an independent third<br />
party. <strong>The</strong>re has been ongoing focus on increasing the response rate to ensure that the analysis<br />
of the data we collect provides us with reliable information on which to base our quality<br />
improvement efforts. <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> analyses the monthly reports they receive, and<br />
implements appropriate action to address any issues of disatisfaction or areas which have been<br />
scored lower than others.<br />
A project to improve on excellence has been ongoing over a number of years. <strong>The</strong> areas of<br />
focus have been based on our patient feedback e.g. admisison and discharge processes,<br />
nursing care and this has resulted in a year on year increase in patient satisfaction scores. <strong>The</strong><br />
focus for this year is Housekeeping and Catering.<br />
<strong>The</strong>re has been an increase in scores in all areas of patient satisfaction except for the<br />
admission process and accommodation. This is evidence of the commitment and actions taken<br />
by the hospital to continually improve patients’ experience. Admission and accommodation will<br />
be a focus of quality improvement in the current year.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
8
5.2 Complaints<br />
In addition to providing all patients with an opportunity to complete a satisfaction survey <strong>BMI</strong><br />
<strong>Harbour</strong> <strong>Hospital</strong> actively encourages feedback both informally and formally. Patients are<br />
supported through a robust complaints procedure, operated over three stages:<br />
Stage 1: <strong>Hospital</strong> resolution<br />
Stage 2: Corporate resolution<br />
Stage 3: Patients can refer their complaint to independent adjudication if they are not satisfied<br />
with the outcome at the other 2 stages.<br />
<strong>The</strong> number of complaints has reduced over the last year. Every complaint is thoroughly<br />
investigated and the patient receives a written response. In addition every effort is made to<br />
address the issues of concern to prevent a recurrence of any similar issues to continuously<br />
improve the quality of care. In the reporting period, no complaints escalated to Stage 2 and all<br />
were resolved at hospital level.<br />
6. National Audit & Guidance<br />
a. NCEPOD<br />
During the Reporting Period, <strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> participated in two NCEPOD studies. <strong>The</strong>y<br />
submitted a nil return for “Are we there yet”, a review of paediatric surgery as they had not had<br />
any paediatric deaths. <strong>The</strong> report was published in October 2011 and the recommendations<br />
have been noted.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> also participated in the Cardiac Arrest Procedures Study and the report is<br />
expected to be published in June 2012.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
9
. National Clinical Audits<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> was only eligible to participate in National Joint Registry audit and all joint<br />
replacements are submitted to this.<br />
6.3 Research<br />
No NHS patients were recruited to take part in research.<br />
6.4 NICE Guidance<br />
<strong>BMI</strong> <strong>Healthcare</strong> has noted the “Patient experience in adult NHS services quality standard”<br />
published in March 2012 and this is being mapped to policies and procedures in place to ensure<br />
that these are being met.<br />
7 Priorities for service development and improvement<br />
Based on what our patients tell us and all of our monitoring activity the Board will be supporting<br />
our focus on the following areas:-<br />
• Ongoing engagement with NHS commissioners to enhance patient choice and service<br />
delivery to NHS patients will be measured by agreed quality indicators<br />
• Further develop and enhance availability of performance and quality indicators for<br />
patients, consultants, referrers and commissioners.<br />
• Audit compliance with Care Bundles” to ensure that these have been effectively<br />
implemented and this will be measured by infection rates.<br />
• Extension of collection of PROMS to include hip and knee replacement for private<br />
patients.<br />
• Patient satisfaction with the admission process and accommodation.<br />
• Improvement in patient satisfaction with nursing and the discharge process.<br />
• Improvements in the management of complaints and responses to patients with roll out<br />
of a corporate tool kit.<br />
<strong>BMI</strong> <strong>Harbour</strong> <strong>Hospital</strong> <strong>Quality</strong> <strong>Accounts</strong> 2011-2012<br />
10