Chief Executive s Statement. I am pleased to welcome you to our Quality Accounts 2015.

Transcription

1 BMI The Meriden Hospital Quality Accounts April 2014 to March 2015

2 Chief Executive s Statement I am pleased to welcome you to our Quality Accounts Now in their sixth year, Quality Accounts continue to provide a truly objective metric for us, and others, to gauge the quality of our 59 hospitals and the services they provide against a broad range of criteria. The past year has seen another step change in the way healthcare providers are externally challenged on the quality they provide. Following a spate of high profile controversies around patient safety, the Care Quality Commission, the UK s health regulator, has introduced a new inspection regime designed to raise standards. No healthcare provider can afford to be complacent and whilst I believe BMI s hospitals provide safe and effective care, we should always be striving for improvement. To this end we recently introduced a new Quality Strategy, which articulates how we will provide the best possible care and strive for continual improvement, and live up to our brand promise to be serious about health, passionate about care. Its four core themes safety, clinical effectiveness, patient experience and quality assurance provide our staff with the platform to consistently deliver the care patients, their insurers, and commissioners expect and deserve. BMI hospitals have been enthusiastic participants in the pilot programme of the new CQC inspection regime for private providers, and to ensure our facilities are prepared we have developed a selfassessment tool to enable hospitals to compare their perceptions of themselves with those of the external inspectors. The rigorous inspection process itself also underpins the sharing of best practice between hospitals which further drives improvement and consistency. BMI Healthcare strives to provide the best care but the ultimate arbiters of whether we succeed are our patients. We are committed to monitoring every aspect of the care we provide, and the results of the detailed questionnaires we ask patients to complete inform improvement. We aim to provide a consistent, high quality patient experience and an environment that empowers our consultants to excel. Providing a dependably high quality of care requires constant focus on improvement; the most recent independent research conducted for BMI shows that over 98% of our patients rate their care as excellent or very good. The information available here 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. Finally I would like to thank all the staff whose application, professionalism and ceaseless commitment to improvement is recognized here and in the positive experiences of the patients we care for. Since I joined BMI late last year, I have witnessed this firsthand on my many visits to our hospitals and I am committed to ensuring we build on that success. Jill Watts, Group Chief Executive

3 BMI The Meriden Hospital is based in Coventry, within the grounds of the University Hospital NHS Trust, and is committed to providing the highest standards of quality care and value. With 48 patient bedrooms, each with en-suite facilities, broadband Internet access, and a modern entertainment system, the hospital provides an ideal environment for excellent clinical care and comfort for patient recovery. Key features of the hospital include 15 outpatient consulting rooms, 3 major operating theatres, Cardiac Cath unit, 4 bed Endoscopy suite, radiology, day case Oncology unit and physiotherapy departments. BMI The Meriden Hospital has its own car park for private patients and their visitors. These facilities combined with the latest in technology and on-site support services enable our consultants to undertake a wide range of procedures from routine investigations to complex surgery. The Physiotherapy Department includes a fully equipped gym and assessment centre with IDD and Alter G machines. BMI The Meriden Hospital undertakes both Choose and Book and Spot contract work for the NHS this represents 50% of the total work carried out at The Meriden Hospital. BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the Health & Social Care Act BMI The Meriden hospital is registered as a location for the following regulated services:- Treatment of disease, disorder and injury Surgical procedures Diagnostic and screening The CQC carried out an unannounced inspection on 12 th compliant with the following standards March 2014 and found we were

4 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 the Meriden 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. There has been development of At corporate level the Clinical Governance Board has an overview and provides the strategic leadership for corporate learning and quality improvement. There has been ongoing focus on robust reporting of all incidents, near misses and outcomes. Data quality has been improved by ongoing training and database improvements. New reporting modules have increased the speed at which reports are available and the range of fields for analysis. This ensures the availability of information for effective clinical governance with implementation of appropriate actions to prevent recurrences in order to improve quality and safety for patients, visitors and staff. 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 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

5 The focus on infection prevention and control continues under the leadership of the Group Head of Infection Prevention and Control, in liaison with the Infection Prevention and Control Lead at BMI The Meriden Hospital and departmental infection prevention and control link nurses. We have had: - Zero MRSA bacteraemia cases/100,000 bed days between April 14 March 15 Zero MSSA bacteraemia cases /100,000 bed days between April 14 March 15 Zero E.coli bacteraemia cases/ 100,000 bed days between April 14 March 15 Zero cases of hospital apportioned Clostridium difficile in the last 12 months. SSI data is also collected and submitted to Public Health England for Orthopaedic surgical procedures. Our rates of infection are; o Hips 1.35% o Knees 1.88% An annual Waste Audit has been completed and submitted. There were no major concerns or issues. Improvements are needed in waste segregation; this will be addressed with staff. Education on waste segregation forms part of the BMI mandatory E-learning programme and is reinforced at departmental meetings. Infection Prevention & Control (IPC) environmental and clinical audits are carried out within all departments of the hospital in accordance with the BMI IPC annual audit programme. The hospital has undertaken audits across a number of different areas, specifically focusing on: Hand hygiene Catheters Environmental Insertion of intravenous cannulas There have been no major issues of concern, with no area generating a need for immediate action or re-audit within six months. We encourage the use of link people within areas to support the IPC Lead with on-going monitoring of areas. The IPC Lead undertakes regular walk rounds of all departments as a way of continuously maintaining high standards.

6 Hand hygiene, aseptic non touch technique and other infection prevention activities are included in the mandatory training for all clinical staff. Antibacterial hand-rub is available at the bedside in the patient rooms. Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly. 1.2 Patient Led Assessment of the Care Environment (PLACE) We believe a patient should be cared for with compassion and dignity in a clean, safe environment. Where standards fall short, they should be able to draw it to the attention of managers and hold the service to account. PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. In 2013 we introduced PLACE, which is the new system for assessing the quality of the patient environment, replacing the old Patient Environment Action Team (PEAT) inspections.

7 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. BMI The Meriden Hospital PLACE assessment involved 50% patient assessors and 50% staff assessors. The results will show how hospitals are performing nationally and locally. Results for BMI The Meriden Hospital are below: Cleanliness Food overall Ward food Organisation food Privacy, Dignity & Well being Condition, appearance & maintenance % 93.44% 91.92% 94.55% 88.89% 97.47% 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 The Meriden 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.

8 We see this as an important initiative to further assure patient safety and care. We audit our compliance with our requirement to VTE risk assessment every patient who is admitted to our facility and the results of our audit on this has shown that over the 12 month period The Meriden Hospital has consistently hit 100% compliance. We intend to maintain this result through training of clinical staff and regular audit of VTE protocols within the hospital. The elements being audited are:- Risk assessment on admission Risk assessment within 24 hours of admission Risk assessment after 7 days, or if patient condition changes BMI The Meriden 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 has been 1 incident of Venous Thrombo-embolism (VTE) during the period April 2014 to March 2015 at BMI The Meriden Hospital There have been 2 incidents of Pulmonary embolism (PE) during the period April 2014 to March 2015 at BMI The Meriden Hospital

9 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. Latest results can be found by going on the online SOLAR system provided to you by Quality Health. For the current reporting period, the tables below demonstrate that the health gain between Questionnaire 1 (pre-operative) and Questionnaire 2 (post operative) for patients undergoing hip replacement and knee replacement at BMI The Meriden Hospital. For Hip Replacements due to the low levels of activity for this procedure BMI Meriden do not have an adjusted Health. BMI Meriden will continue to strive to ensure all questionnaires are completed for patients undergoing a Hip Replacement in order to achieve compliance. For knee replacements BMI The Meriden Hospital at a score of is below the English average adjusted Health Gain. The Q1 results are slightly above the national average whilst the Q2 results are slightly below the average. BMI The Meriden Hospital will continue to strive to ensure that all patients undergoing a Knee Replacement will complete a questionnaire at their pre assessment in order to improve compliance moving forward.

10 April 14 September 14 BMI The Meriden Hospital Oxford Hip average Q1 Q2 Health gain between reporting periods * * No data available as less than 30 patients England Copyright 2013, The Health and Social Care Information Centre. All Rights Reserved. Oxford Knee average April 14 September 14 Health gain between reporting Q1 Q2 periods BMI The Meriden Hospital 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

11 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 Local Progress with ERP Implementation as follows: Director of Nursing and other clinical staff involved with Enhanced Recovery of patients have attended a conference day. Carbohydrate Loading is in place as required. Telephone pre-assessment now in place to increase numbers of patients who receive pre assessment prior to surgery. Achieved 98% of patients pre-assessed in March 2015 Pre- surgery Physiotherapy joint classes implemented within the hospital Combined Joint physiotherapy and pre-assessment clinics to begin June 2015 Information regarding the patient s pathway is delivered at pre assessment. Multidisciplinary Team working together to optimise early discharge. Post-operative discharge telephone calls in place 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.

12 This data is tracked on a monthly basis and reviewed by the Director of Nursing to monitor any trends or concerns. The data is fed back through the Integrated Governance Committee and Medical Advisory Committee. All unplanned readmissions and returns to theatre are looked at in

13 detail to ensure there are no clinical concerns and root cause analysis undertaken where required. 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. Areas of current focus include: Information pack Timeliness of pharmacy services Discharge time and process 3.2 Complaints

14 In addition to providing all patients with an opportunity to complete a satisfaction survey BMI The Meriden 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.. A small number of stage 1 complaints each month will result in being reopened, this is where the complainant states their dissatisfaction at our complaint response. In the majority of cases a reopened complaint is not because our written response is of a poor quality and does not adequately answer their concerns. In most instances it relects our turning down their disproportunate request for compensation or reimbursement of monies. It should be noted that the complaint process does not allow for compensation, although realistic and appropriate goodwill gestures can be made where it can be shown that the patient has received sub-optimal clinical care. A small proportion of complaints will escalate to stage two, this is only when every effort has been made to resolve the concerns at stage 1, local resolution. There has been one reported complaint which escalated to stage 3 within the timeframe to This was not an NHS patient and related to costs incurred for the procedure

15 performed. The complaint was upheld.the numbers of complaints which are also a reported incident are relatively low. Where a specific complaint results in an identified action or change in practice, this is documented and recorded in our Closing the Loop on Complaints folder so that we are able to monitor and evidence that appropriate actions are being taken to improve clinical practice. General themes and trends of our complaints: A recurring cause of complaint at BMI The Meriden Hospital is in association with the private market and around financial issues. Patients often being dissatisfied at the costs associated with investigations despite the fact that BMI Healthcare does publish associated pricing. A number of complaints are associated with waiting time in the out-patient department. To address this waiting times are carefully monitored by staff and patients kept fully informed of waiting times and possible delays. Staff also track Consultant arrival times and late arrivals are recorded and monitored. Cancellation of surgery has also generated a small number of complaints. Predominantly due to late theatre and over-runs from earlier theatre lists, theatre lists are now carefully monitored and managed throughout the day to ensure cancellations are reduced 4. CQUINS

16 Below is a table showing the achieved full year performance at BMI The Meriden Hospital Friends and Family 1.1 Description of Indicator Performance Early Implementation of FFT - show implementation by October 2014 to daycase and outpatients. FFT - achieving early implementation / phased expansion in line with national milestones (Y/N) Q4 yes Friends and Family 1.2 Description of Indicator Performance Increased or maintained response rate, Q1 20% and Q4 25% Q4 Increased response rate 20% by Q1 and 25% by Q4 29.6% 31.77% NEWS Scoring Description of Indicator Real time audit of NEWS scoring ( Early Warning ) for all patients with a stay greater than 24 hours Q4 Performance 75.92% 100% Vascular Access Care Bundle Description of Reduce complications associated with the use of Indicator peripheral vascular access device. Q4 Performance 100% 5. Clinical Audits BMI The Meriden Hospital was only eligible to participate in Joint Registry audit and all joint replacements are submitted to this. BMI hospital data is from page 196 onwards in attached latest NJS report. 6. Research No NHS patients were recruited to take part in research. 7. Priorities for service development and improvement Continued development and expansion of Cardiac catheterization service

17 Replacement of static stack system within theatres, to maintain and expand complex gynaecology, orthopaedic and laparoscopic procedures Expansion of the ward waiting area to incorporate a family area/discharge lounge Development of an ambulatory care unit within the hospital for minor procedures Development of a pharmacy within the hospital, to improve the pharmacy service for inpatients and provide a service for out-patients 8. Mandatory Quality Indicators 8.1 The value of the summary hospital-level mortality indicator (SHMI) for the BMI The Meriden Hospital for the reporting period. Highest Lowest No data Oct 2012 Jun BMI The Meriden Hospital considers that this data is as described for the following reasons: No reported mortality for the above period. 8.2 The BMI Meriden Hospital patient reported outcome measures scores for (i) Groin hernia surgery Highest Lowest No data Apr 14 Sept BMI The Meriden Hospital considers that this data is as described for the following reasons Less than 30 patients going through the process, therefore the site cannot be scored (ii) Varicose vein surgery Highest Lowest

18 No data Apr 14 Sept BMI The Meriden Hospital considers that this data is as described for the following reasons: Less than 30 patients going through the process, therefore the site cannot be scored (iii) Hip replacement surgery Highest Lowest No data Apr 14 Sept BMI The Meriden Hospital considers that this data is as described for the following reasons: Less than 30 patients going through the process, therefore the site cannot be scored (iv) Knee replacement surgery during the reporting period. Highest Lowest Apr 14 Sept BMI The Meriden Hospital considers that this data is as described. 8.3 (i) The percentage of patients aged 0-14 readmitted to a hospital which forms part of BMI The Meriden Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Highest Lowest 0% Apr 14 - Mar BMI The Meriden Hospital considers that this data is as described for the following reasons: The hospital does not admit patients under the age of 16 years.

19 8.3. (ii) The percentage of patients aged 15 or over readmitted to a hospital which forms part of BMI The Meriden Hospital within 28 days of being discharged from a hospital which forms part of the hospital during the reporting period. Highest Lowest 0.09% Apr 11 Mar BMI The Meriden Hospital considers that this data is as described. BMI The Meriden Hospital has taken the following actions to improve this percentage score and so the quality of its services, by: Conducting root and branch analysis of factors which contributed to readmission to further reduce the percentage 8.4 BMI The Meriden Hospital's responsiveness to the personal needs of its patients during the reporting period. Highest Lowest 98.2% BMI The Meriden Hospital considers that this data is as described due to our continued commitment to our patients and the care in they receive. BMI The Meriden Hospital has taken the following actions to improve this percentage score and so the quality of its services by: Continuing to monitor all patient feedback through monthly quality meetings and actions implemented to as a result of this to improve the quality of patient care in all areas In response to comments made on the patient surveys regarding length of time to answer call bells and pain management Intentional Rounding is to be introduced from May The percentage of patients who were admitted to BMI The Meriden Hospital and who were risk assessed for venous thromboembolism during the reporting period. Highest Lowest

20 100% Apr 14 Jan BMI The Meriden Hospital considers that this data is as described as all NHS patient records are audited and VTE is confirmed as having been undertaken at pre-assessment and reviewed after 24 hours. 8.6 The rate per 100,000 bed days of cases of C difficile infection reported within amongst patients aged 2 or over during the reporting period. Highest Lowest 0 Apr 13 Mar BMI The Meriden Hospital considers that this data is as described. 8.7 The number and, where available, rate of patient safety incidents reported within BMI The Meriden 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 Highest Lowest 139 Oct 13 Sep Rate of patient safety incidents reported (Incidents per 100 Bed Days) Highest Lowest Oct 13 Sep Number of patient safety incidents that resulted in severe harm or death Highest Lowest

21 3 Oct 13 Sept Percentage of patient safety incidents that resulted in severe harm or death (Incidents per 100 Admissions) Highest Lowest 0.25% Oct 13 Sept BMI The Meriden Hospital considers that this data is as described for the following reasons: Robust incident reporting. BMI The Meriden Hospital has taken the following actions to improve this percentage score, and so the quality of its services; conducting root and branch analysis of factors which contributed to adverse clinical incidents, these are then reported to Heads of Departments and an action plan formulated, implemented and reviewed to improve outcomes Mandatory AIMs training for all ward registered nurses and HCA s Use of the SBAR assessment tool within the clinical areas to monitor significant changes in the patient s condition 8.8 The percentage of staff employed by the (name of hospital) during the reporting period, who would recommend BMI The Meriden Hospital as a provider of care to their family or friends. Highest Lowest

22 78% BMI The Meriden Hospital considers that this data is as described. BMI The Meriden Hospital has taken the following actions to improve this percentage, and so the quality of its services; Engaging with staff through staff forums Improving communication through a monthly newsletter Frequency of Clinical Huddle increased from thrice-weekly to Monday-Friday 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 BMI The Meriden Hospital as a provider of care to their family or friends. Highest Lowest 83.9% Jun 13 Jan BMI The Meriden Hospital considers that this data is as described. BMI The Meriden Hospital has taken the following actions to improve this percentage score, and so the quality of its services, by: Close monitoring of patient feedback through monthly Quality meetings with Heads of Departments and the quality manager within the hospital Implementation of robust action plans as required and reviewed on a regular basis.