group chief executive’s statement€¦ · advisory conference for the chairs of our hospital...

of 28 BMI Mount Alvernia Quality Account 2015/16 - Date: 13 May 2016

Group Chief Executive’s Statement

I am pleased to welcome you to our Quality Accounts 2016.

Our 2016 Quality Accounts provide a transparent picture of BMI Healthcare’s performance over the

period covered and present the outcomes of objective metrics on the quality status of our 59 hospitals

and clinics.

Across BMI Healthcare, we have adopted a systems-based approach to the management of clinical risk

with the focus being on establishing effective systems, processes and controls across the business, rather

than focusing on the acts or omissions of individual employees. Our goal is to establish a managerial

culture which promotes proactive consideration of clinical risks, so that appropriate mechanisms and

strategies are put in place to control and minimise future risk.

A comprehensive clinical governance framework exists across BMI Healthcare to ensure patient safety.

As part of the framework, every effort has been made to ensure strategies are in place to look both

prospectively and retrospectively across the organisation. This means that our focus is on both

preventing risk and identifying clinical outcome trends across the business, as well as ensuring

appropriate controls are in place at all levels.

Because of the inherent risks associated with being a patient in a healthcare system and our continued

and consistent focus on patient safety, a key part of our plan is to ensure that every effort is made to

reduce the likelihood and consequence of an adverse event or outcome associated with the treatment

of a patient in our hospital. No healthcare provider can afford to be complacent and whilst I believe BMI

Healthcare’s hospitals provide safe and effective care, we are always striving for improvement. And

indeed, our internal audit processes continue to identify areas for ongoing improvement and investment.

During the last year, we have also seen the onset of the new Care Quality Commission (CQC)

inspection regime and a number of our hospitals have now been through the new process, with a steady

flow of inspections expected over the next 12 months.

BMI Healthcare’s brand promise is 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 that patients, their insurers and commissioners expect and

deserve. We continue seek new ways to enhance engagement with our Consultants and Allied Health

Professionals, as well as our own staff, around important clinical governance topics like the focus on

Duty of Candour. During the year we held a workshop for our medical leaders at our National Medical

Advisory Conference for the Chairs of our hospital Medical Advisory Committees and provided updated

policies and guidance for our staff. We regularly communicate with our staff and Consultants the

importance of using the recognised procedures such as the World Health Organisation ‘Safer Surgery

Checklist’ and we are clear that patient safety remains our top priority. As a learning organisation, we

make sure that learning from incidents and a culture where it is safe to speak up are cultivated and

nurtured by our leaders.

We are shortly to introduce Patient Recorded Outcome Measures (‘PROMs’) for all our private

patients, as well as those outcomes we already capture for our NHS patients. The new national Private

Healthcare Information Network (PHIN) website, which will launched shortly will also enable patients

to make informed choices about their Consultants and care, through a comprehensive website covering

the most popular private procedures and their outcomes.


BMI Healthcare strives to provide superior patient care, but ultimately our patients are the best judge of

their care and treatment. We are committed to monitoring every aspect of the care we provide, and we

invest significantly in obtaining patient feedback on all aspects of their stay with us. We also measure

national survey information such as the ‘Friends and Family’ test and use all patient feedback to guide

our investment plans, the treatments we offer and the all-round high quality patient experience we

aspire to give. Even with relatively high scores, we strive to improve, and in the most recent figures at

the end of 2015, patient satisfaction with overall quality of care had risen to 98.1%, with some of our

hospitals scoring 100%.

The information available here in the Quality Accounts has been reviewed by the BMI Healthcare

Clinical Governance Committee 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 dedication to caring for our patients and commitment to

improvement are recognised here and in the positive experiences of the patients we serve every day.

Jill Watts, Group Chief Executive


Hospital Information

BMI Mount Alvernia Hospital is situated in Guildford Surrey. The hospital is part of BMI Healthcare with

a nationwide network of hospitals and clinics performing more complex surgery than any other private

healthcare provider in the country. Our commitment is to quality and value, providing a wide range of

acute surgical and medical services for both elective and urgent care patients, within a friendly and

professional environment. Our vision is to be part of a Group that creates a world of consumer led

care, where individuals choose our extensive health and well-being services throughout their lives, and

in doing so help improve the health of the nation.

Accommodation is provided in 67 individual rooms, 3 of which can convert to twin occupancy, all with

the comfort of en-suite facilities, satellite television and telephone. There is also a 6 bay ambulatory care

unit for those patients undergoing minor procedures. 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 theatre suite comprises 3 main theatres, two of which have laminar flow, 8 patient recovery bays,

offsite TSSU together with supporting areas. The Ambulatory Care Unit comprises 2 endoscopy/minor

ops theatres, 6 patient recovery bays, consulting room, treatment room, reception and waiting room.

The Consulting Room Suite has 11 consulting rooms including dedicated ENT, ophthalmic and

cardiology rooms, 2 nurse treatment rooms are also available along with a registration desk, 2 waiting

areas one with a coffee shop .

The Imaging Department provides a comprehensive range of diagnostic imaging services including all

types of general x-rays, digital screening, mammography, bone densitometry, a full ultrasound service including Doppler. The department also has a state of the art 128 slice CT scanner, a 1.5 Tesla MRI

scanner. A Nuclear Medicine Department provides a Gamma Camera and a mobile PETCT service.

A dedicated physiotherapy service provides clinical specialty trained physiotherapists to both in and

outpatients. The hospital also provides a full range outreach service, which includes hydrotherapy

treatment, in GP surgeries and gymnasiums across the Guildford area.


The Pharmacy Department provides both inpatient and outpatient services.

Consultant led care is supported by caring and professional medical staff, with a dedicated registered

medical officer (RMO) covering the twenty four hour period. The nursing service is led by the Director

of Nursing. There is a senior nurse on duty at all times, in order to support the co-ordination of a

seamless service for patients utilising the service.

New developments within the last year include

o The opening of a second laminar flow theatre suite

o Improved physiotherapy services with the introduction of an AlterG anti-gravity treadmill to

support patients as part of their rehabilitation programme

o Introduction of a bariatric surgery service

Future developments include:

o An in-house PET CT scanner

o Introduction of an Urgent Care Centre

o Introduction of ophthalmology services

o 24/7 urgent care Medical unit

The number of NHS patients seen within BMI Mount Alvernia Hospital between April 2015 and March

2016 equates to 4.4% total in-patients, 9.4% day cases and 14% outpatient first attendance and 4.2%

outpatient follow up. This equates to 5.9% of our patient base. The table below provides a further

breakdown.

Table 1: NHS patients

AGE BAND INPATIENT OVERNIGHT

INPATIENT DAYCASE

OUTPATIENT FIRST ATTENDANCE

OUTPATIENT FOLLOW UP

Adults aged 18 to 64 years

30 295 458 431

Adults aged 65 to 74 years

9 76 105 123

Adults aged 75+ years

6 43 52 62

BMI Healthcare are registered as a provider with the Care Quality Commission (CQC) under the

Health & Social Care Act 2008 as well with the Hospital Improvement Scotland (HIS) and Healthcare

Inspectorate Wales( HIW) for our hospitals outside of England. BMI Mount Alvernia is registered as a

location for the following regulated services:-

Treatment of disease, disorder and injury

Surgical procedures

Diagnostic and screening

These regulatory bodies carry out inspections of our hospitals periodically to ensure a maintained

compliance with regulatory standards.


The CQC carried out a comprehensive inspection of the hospital on 12 and 13 November 2014, as part

of a pilot programme of inspections in independent healthcare settings. The inspection considered the

following areas:

Are services safe?

Are services effective?

Are services caring?

Are services responsive?

Are services well-led?

As this was a pilot inspection and was undertaken to help develop the methodology the CQC would use

to inspect all independent providers in the future, the hospital did not receive a rating following the

inspection.

The CQC report identified areas of outstanding practice as well as areas which required improvement.

In response to the report BMI Mount Alvernia prepared an action plan to address the four areas where

additional compliance actions were requested. These relate to:

Notification of serious incidents to the CQC (complete)

Amendment to the statement of purpose document to ensure it accurately reflects any limitations in

service provision (complete)

The formal arrangements and training to support patients living with dementia or learning difficulties

(complete)

Strengthen feedback mechanisms following serious incident investigation (complete)

BMI Mount Alvernia Hospital has a local framework through which clinical effectiveness, clinical incidents

and clinical quality is monitored and analysed, and where appropriate action is taken to continuously

improve the quality of care provided. This is through the work of a multidisciplinary group and the

Medical Advisory Committee.

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. This data (once PHIN is fully established and finalised) will be made available to common

standards for inclusion in comparative metrics, and is published on the PHIN website

http://www.phin.org.uk.

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.

CQC Ratings Grid

As referred to above, BMI Mount Alvernia Hospital did not receive a rating following the inspection

undertaken in November 2014. A full announced inspection is due to be carried out in July 2016.

Safety

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, and link nurse in BMI Mount Alvernia.

Between April 2015 to March 2016, the hospital had:

o MRSA bacteraemia cases/0.00 per100,000 bed days

o MSSA bacteraemia cases /0.00 per 100,000 bed days

o E.coli bacteraemia cases/ 0.00 per100,000 bed days

o 0 cases of hospital apportioned Clostridium difficile in the last 12

months.

o SSI data is also submitted to Public Health England for Orthopaedic

surgical procedures. Our rates of infection are;

o Hips 2.27% (rate per number of procedures)

o Knees 2.63% (rate per number of procedures)

BMI Mount Alvernia Hospital has a comprehensive Infection Prevention and Control audit programme

which involves both clinical and non-clinical staff. Audits include hand hygiene, the use of anti-microbial,

environmental assessments and national Infection Prevention Society Quality Improvement Tools

(IPSQIT). Participating in the IPSQIT programme enables BMI Mount Alvernia Hospital to demonstrate

an objective and transparent approach to both process and practice improvement.

Bare Below the Elbow & Hand Hygiene Audit

BMI Mount Alvernia Hospital conducts monthly auditing of hand hygiene on the basis of the Five

Moments WHO directive. Each department will have Link personnel who complete the assessments on

different staff group. For the past year, Mount Alvernia has an overall compliance of 97.32% across all

departments. Strict adherence to our Clinical Uniform Policy of Bare Below the Elbows is being audited.

Staffs that breach compliance are addressed at the point of concern or through action plans and staff

meetings providing a cohesive approach to both WHO 5 moments and our Bare Below the Elbows

policy.

o Hand hygiene workshop is being held monthly as part of the Mandatory IPC training where hand

hygiene technique with both hand washing and alcohol hand rub is being assessed. Competencies for

hand hygiene are provided to all members of staff. We got a very positive feedback from all staff

attending the practical sessions. Non- Clinical Staff (IPC Awareness) training had 100% compliance

and for Clinical Staff (IPC for Healthcare) is 99%. Mount Alvernia had achieved 100% compliance to

ANTT Competency training.


Sharps Awareness & Compliance Audit

At BMI Mount Alvernia Hospital an external audit was carried out by Daniels Healthcare Representative.

Annual Sharps audit was conducted in line with EU Directive 2010/32/EU. All the wards and other

departments where sharps are in use were audited. It is an annual check to assess compliance in the use

of sharps containers. The general findings and recommendations are highlighted to all Heads of the

Departments. As a result of this audit, IPC link practitioner will be having a Sharps Awareness study

session to disseminate information and retrain their staff within their department.

QIT IPS Environmental Cleanliness Annual Audit

All clinical departments are involved in IPS QIT environmental audits on an annual basis. The audits

cover general IP&C management, as well as cleanliness, hand hygiene, PPE, waste & sharps management,

standard precautions, etc. Each section is given a percentage score and then an overall score is

calculated. Action plans are in place for areas where improvement is required. Each department is

audited using the IPS QIT tools for environmental compliance.

Saving Lives / High Impact Interventions / Care Bundles

A selection of High Impact Intervention/Care bundles audits are currently undertaken on a quarterly

basis. These are for the insertion and ongoing management of patient with urinary catheter, peripheral

cannula and central venous catheter. Results are fed back to the Clinical Governance monthly meetings

and action plans are devised and discussed at Link Practitioner meetings and to the quarterly IPC

Committee meeting.

From April 2015 – March 2016, High Impact Intervention Care bundles had shown 100% compliance

from all departments involved in the audit. The most recent audit results, which confirm 100%

compliance, are detailed in Table 2 below.

Table 2: Care Bundles (January-March 2016)

Care Bundles Oncology Wards Theatres Radiology

Peripheral Insertion 100% 100% 100% 100%

Peripheral ongoing 100% 100% NA NA

CVL insertion NA NA 100% NA

CVL ongoing 100% 100% NA NA

Catheter insertion NA 100% 100% NA

Catheter ongoing NA 100% NA NA

SSI pre op NA NA 100% NA

SSI intra op NA NA 100% NA

SSI post op NA 100% NA NA


Environmental cleanliness is also an important factor in infection prevention and our patients rate the

cleanliness of our facilities highly. The two graphs detailed below indicate patient satisfaction scores for

both bathroom and room cleanliness over the previous year, indicating an overall increase in the level of

satisfaction over the period.

Graph 1: Bathroom Cleanliness

Graph 2: Room Cleanliness

Patient Led Assessment of the Care Environment (PLACE)

At BMI Healthcare, 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.


Since 2013, PLACE has been used for assessing the quality of the patient environment, replacing the old

Patient Environment Action Team (PEAT) inspections.

The assessments involve patients and staff who assess the hospital and how the environment supports

patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on the

care environment and does not cover clinical care provision or how well staff members are doing their

job. The results will show how hospitals are performing nationally and locally.

The results of the audit undertaken in May 2015 are detailed in graph 3 below.

Graph 3: PLACE audit results 2015

Actions taken to address areas of concern include:

o Ongoing refurbishment plans are in placed in regards to the condition, appearance and

maintenance of the hospital.

o A new dementia monitor was included in last year’s assessment. In response to improving

staff understanding of dementia care Lunch & Learn sessions were arranged, and a

corporate training package is now in place to support this further. A dementia kit to

support the recommendations is being put in placed in case a patient suffering with

dementia will be admitted to the hospital.

o With the changes in the hospital’s catering services, a big dropped was noticed in the audit

made. Spot checks of the kitchen had been done by the IPC team with recommendations

to help improve the quality and service that they offer to our patients.

An action plan has been developed to address any areas that fall below 100% and there are

mitigating processes in place to ensure that all patients receive the individualised care that they

require.

of 28 BMI Mount Alvernia Quality Account 2015/16 - Date: 13 May

2016

Duty of Candour

A culture of Candour is a prerequisite to improving the safety of patients, staff and visitors as well as the

quality of Healthcare Systems.

Patients should be well informed about all elements of their care and treatment and all staff have a

responsibility to be open and honest. This is even more important when errors happen.

As part of our Duty of Candour, we will make sure that if mistakes are made, the affected person:

Will be given an opportunity to discuss what went wrong

What can be done to deal with any harm caused

What will be done to prevent it happening again

Will receive an apology.

To achieve this, BMI Healthcare has a clear policy - BMI Being Open and Duty of Candour policy.

We are undertaking a targeted training programme for identified members of staff to ensure

understanding and implementation in relation to the Duty of Candour.

Venous Thrombo-embolism (VTE)

BMI Healthcare holds VTE Exemplar Centre status by the Department of Health across its whole

network of hospitals including BMI Mount Alvernia Hospital. BMI Healthcare was awarded the Best VTE

Education Initiative Award category by Lifeblood in February 2013 and were runners up in the Best VTE

Patient Information category.

We see this as an important initiative to further assure patient safety and care. We audit our compliance

with our requirement to VTE risk assessment every patient who is admitted to our facility and the

results of our audit on this has shown that the hospital consistently achieves 100% compliance with VTE

assessment on admission. This is detailed within graph 4 below.

Graph 4: VTE Risk Assessment on admission


2016

BMI Mount Alvernia 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.

Where a possible VTE is identified a pre VTE Root Cause Analysis is completed in order to establish

whether it was preventable or non-preventable. BMI Mount Alvernia had no incidents of preventable

VTE reported during 2015/16. The data for reported VTE rate per 100 admissions is detailed in graph 5.

Graph 5: VTE Rate per 100 admissions

BMI Mount Alvernia Hospital investigates all possible cases of preventable hospital acquired VTE using a

pre root cause analysis tool. There were no preventable cases of VTE reported during this year.

Sign Up for Safety Campaign

In December 2015 BMI Health applied to Sign up for Safety by submitting our actions for the following

five pledges:

o Put safety first – Committing to reduce avoidable harm in the NHS by half through taking a

systematic approach to safety and making public your locally developed goals, plans and

progress. Instill a preoccupation with failure so that systems are designed to prevent error and

avoidable harm

o Continually learn – Reviewing your incident reporting and investigation processes to make

sure that you are truly learning from them and using these lessons to make your organisation

more resilient to risks. Listen, learn and act on the feedback from patients and staff and by

constantly measuring and monitoring how safe your services are

o Be honest – Being open and transparent with people about your progress to tackle patient

safety issues and support staff to be candid with patients and their families if something goes

wrong


2016

o Collaborate – Stepping up and actively collaborating with other organisations and teams; share

your work, your ideas and your learning to create a truly national approach to safety. Work

together with others, join forces and create partnerships that ensure a sustained approach to

sharing and learning across the system

o Be supportive – Be kind to your staff, help them bring joy and pride to their work. Be

thoughtful when things go wrong; help staff cope and create a positive just culture that asks why

things go wrong in order to put them right. Give staff the time, resources and support to work

safely and to work on improvements. Thank your staff, reward and recognise their efforts and

celebrate your progress towards safer care.

BMI Healthcare as a company was successful in their application with Sign

up for Safety in March 2016. Sign up for safety is a campaign to make all

our healthcare services the safest in the world. Whilst predominantly

focused on the NHS the campaign welcomes independent healthcare

companies or individual hospitals to participate to make all healthcare

services safer. The ambition of sign up to safety is to halve avoidable harm

over the next three years and save 6,000 lives as a result.

By signing up to the campaign we have committed to listening to patients,

carers and staff, learning from what they say when things go wrong and

taking action to improve patient’s safety helping to ensure patients get harm free care every time,

everywhere.

Effectiveness

Patient Reported Outcome Measures (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, BMI Mount Alvernia Hospital participated the tables below

demonstrate the health gain between Questionnaire 1 (Pre-Operative) and Questionnaire 2 (Post–

Operative) for patients undergoing hip replacement and knee replacement at BMI Mount Alvernia

Hospital.

The latest PROMs data available from HSCIC (Period: April 2014 – March 2015) is detailed in the graphs

below:


2016

Graph 6: Hip Replacement

Graph 7: Knee Replacement


2016

Graph 8: Groin hernia

Graph 9: Varicose Veins

0.000 0.000

0.747

0.000 0.000

0.841

0.000 0.000 0.0950.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

Mount Alvernia Hospital BMI Healthcare Average National Average

PROMs -Varicose Veins (EQ-5D Index)

Pre-Op Post-Op Adjusted Health Gain

Adjusted average health gains have been calculated using statistical models which account for the fact

that each provider organisation deals with patients with different case-mixes. This allows for fair

comparisons between providers and England as a whole. Random variation in patients mean that small

differences in averages, even when case-mix adjusted, may not be statistically significant.

Over the past year BMI Mount Alvernia hospital had a questionnaire count of less than 30 and as such

in order to protect patient confidentiality the adjusted health gain score is not available.


2016

Enhanced Recovery Programme (ERP)

The ERP is about improving patient outcomes and speeding up a patient’s recovery after surgery. ERP

focuses on making sure patients are active participants in their own recovery and always receive

evidence based care at the right time. It is often referred to as rapid recovery, is a new, evidence-based

model of care that creates fitter patients who recover faster from major surgery. It is the modern way

for treating patients where day surgery is not appropriate.

ERP is based on the following principles:-

1. All Patients are on a pathway of care

a. Following best practice models of evidenced based care

b. Reduced length of stay

2. Patient Preparation

a. Pre Admission assessment undertaken

b. Group Education sessions

c. Optimizing the patient prior to admission – i.e. HB optimisation, control 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

At Mount Alvernia Hospital a working party with representation from theatre, physiotherapy, nursing

and pre-assessment was set up to support implementation of the programme, which has been launched

in Orthopaedics. The programme will be rolled out into the other specialties over the next year.

Initiatives introduced to support the implementation include the ‘five day rule’. This rule allows for the

relevant pre-assessment to take place within appropriate timescales and provides patients with realistic

expectations as to their length of stay and recovery programme.

Progress on implementation is discussed at the Nutritional Steering Group. A corporate review of the

nutritional policy to include focus on enhanced recovery programme and carbohydrate loading pre-

surgery is currently being undertaken.


2016

Unplanned Readmissions & Unplanned Returns to Theatre

At BMI Mount Alvernia Hospital unplanned readmissions within 28 days of discharge and unplanned

returns to theatre are both considered as recognised Mortality and Morbidity categories. All cases are

investigated and a report detailing any findings and learning presented at the Clinical Governance

Committee.

Between March 2015 and April 2016 BMI Mount Alvernia Hospital reported a total of 11 cases of

unplanned re-admission within 31 days of discharge, which indicates a 1000% increase when compared

with the previous year. Despite this increase the rate of unplanned re-admissions at Mount Alvernia

remains below the NHS national average at 2.48 per 1000 bed days as detailed in the graph

below.

Graph 10: Unplanned readmissions

Between March 2015 and March 2016 BMI Mount Alvernia Hospital reported a total of 7 cases of

unplanned return to theatre, which indicates a 100% increase when compared with the previous year.

Graph 11: Unplanned return to theatre


2016

During this time period, a key focus for BMI Mount Alvernia Hospital has been to increase the reporting

of all incidents including those patients who are re-admitted or return to theatre in order that any

learning can be identified and shared. It is anticipated improvement in the levels of reporting attribute to

the apparent rise in the number of cases.

Patient Experience

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.

Graph 12: Overall Quality of Care

A Patient Satisfaction Committee convened in the past year in order to support review of the results of

the satisfaction survey and jointly agree actions to address areas of deficiency. The outcome of the work

of this committee, and the hard work of all staff working within the hospital is an improvement in group

standing from 53 in March of 2015 to 19 in March 2016. Further evidence of staff engagement is

identified from the rate of returns which has increased from 7% to 60% for the short postcard

questionnaire. This improvement is captured in the graph below.

Graph 13: Response Rates


2016

The graphs below provide examples of responses for the following areas with a comparison of the

whole of BMI:

o Overall impression of the arrival process

o Overall impression of nursing care

o Did you feel you were treated with dignity and respect

o Overall impression with catering

o Overall impression of the discharge process

Graph 14: Arrival Process

Graph 15: Nursing Care


2016

Graph16: Dignity and Respect

Graph 17: Catering

Graph 18: Discharge


2016

The graphs evidence that overall BMI Mount Alvernia Hospital compare favourably with both the score

for the previous year and BMI as a whole. The exception to this is noted within the catering graph which

indicates higher level of disatisfaction when compared to the group as a whole. This is a main area of

focus for the Patient Satisfaction Committee, which is attended by the catering manager, in order to

share suggestions for improvement.

Complaints

In addition to providing all patients with an opportunity to complete a Satisfaction Survey BMI Mount

Alvernia 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.

The graph below shows the number of written complaints received per 100 admissions during 2015 (n=

27) when compared with the previous six years, indicating a slight increase over the past two years.

Graph 19: Written complaints per 100 admissions

All complaints received were managed as Stage 1.

At BMI Mount Alvernia Hospital analysis of the complaints received indicated that a number were

multifactorial. The main themes emerging during this period were in relation to clinical treatment,

communication and finance.

Where review of a complaint indicates that an incident occurred which was not reported at the time, a

form is completed retrospectively and entered onto the Sentinel system.


2016

The investigation and response to complaints at BMI Mount Alvernia Hospital is considered an

opportunity to learn and improve the quality of services provided. Feedback is provided directly to the

individuals involved.

CQUINS

The focus of the 2015/16 CQUINS agreed with the CCG at BMI Mount Alvernia were based on

improved levels of reporting and learning from thematic analysis and investigation of agreed mortality

and morbidity indicators. The targets for Q1,2 and 3 were met. A response to the evidence submitted

for Q4 is awaited. The table below provides and overview of the improvement goal specification and

actions to achieve them.

Table 3: CQUINS

Improvement Goal

Specification Q1 & 2 Q3 Q4

Indicator

2.1a Increased

levels of

reporting

Report on baseline number

of incidents per 100

admissions or bed days in

2014/2015. Plan for

improvement of incident

reporting in Quarter 3 and

4 of current year

100% actions achieved in

time for the improvement

of incident reporting Report detailing incidents

measured overall and by

ward or department

Increase in incidents

per 100 bed days or

admissions compared

to baseline in 2014/15

100% 100% Awaited Indicator

2.1b Thematic

analysis of

incidents

Baseline report on the

proportion of Clinical

Governance Committee

meetings that have

received a thematic analysis

of incidents with an

improvement plan in

2014/15 Improvement plan to

enable increase of thematic

analysis reporting

Quarterly report to

Clinical Governance

committee detailing

thematic analysis of

incidents with an

improvement plan

compared to baseline 100% actions achieved in

time for the improvement

of incident reporting

Quarterly report to

Clinical Governance

committee detailing

thematic analysis of

incidents with an

improvement plan

compared to baseline

100% 100% Awaited Indicator

12.2 Mortality

and

Morbidity

Review

Baseline report on the

number of mortality and

review reports presented

to the Clinical Governance

Committee in 2014/2015

Report on number of

mortality and morbidity

reports submitted to

Clinical Governance

Committee confirming

that all eligible cases have

been reviewed during the

quarter

Report on number of

mortality and

morbidity reports

submitted to Clinical

Governance

Committee confirming

that all eligible cases

have been reviewed

during the quarter 100% 100% Awaited


2016

Additional assurance for the CCG is achieved through the attendance of a member of the clinical

governance team at the Clinical Governance Committee.

National Clinical Audits

BMI Mount Alvernia Hospital participates in the National Joint Registry Audit and all joint replacements

data is submitted to this.

During 2015 the hospital undertook a total of 177 operations (124 hip procedures and 53 knee

procedures). The overall consent rate for the year was 97%. Totals for the hospital are detailed in the

tables below.

Table 4: Total cases submitted

Totals for this hospital 2015 Year to date:

2016

Total completed operations 177 70

Hip procedures 124 40

Knee procedures 53 29

Ankle procedures 0 1

Elbow procedures 0 0

Shoulder procedures 0 0

NJR consent rate 97% 100%

Table 5: Operations by month (2015)

Month Completed

operations Hips Knees Ankles Elbows Shoulders Consent rate

January 27 16 11 0 0 0 100

February 15 7 8 0 0 0 86

March 22 12 10 0 0 0 86

April 12 10 2 0 0 0 100

May 3 2 1 0 0 0 100

June 15 9 6 0 0 0 100

July 8 6 2 0 0 0 100

August 9 8 1 0 0 0 100

September 18 15 3 0 0 0 100

October 19 18 1 0 0 0 100

November 17 14 3 0 0 0 100

December 12 7 5 0 0 0 100

Research

No NHS patients were recruited to take part in research.


2016

Priorities for Service Development and Improvement

At BMI Mount Alvernia hospital there are several initiatives for service development and improvement

which include:

o Introduction of an Urgent Care Centre

o Develop staff to run an Urgent Care Medical Unit

o Improve and extend the ambulatory care (ACU) facility

o Introduce a high dependency (HDU) unit

o Work in partnership with Guildford and Waverley CCG and General Practitioners in order to

increase Choose and Book referrals or NHS work

o Education of staff in dementia care in order to support patients who may have this diagnosis but

coming to MAH for treatment or surgery for other problems.

o Bariatric service

o Strengthen the ‘On call' service for Oncology patients who have urgent care needs out of hours

Quality Indicators The below information provides an overview of the various Quality Indicators which form part of the

annual Quality Accounts. Where relevant, information has been provided to explain any potential

differences between the collection methods of BMI Healthcare and the NHS.

All data provided by BMI Healthcare is for the period April 2015-March 2016 to remain consistent

with previous Quality Accounts, whilst the NHS data may not be for the same period due to HSCIC

data availability. The NHS data provided will be the latest information available from the HSCIC

website.

Table 6: Quality Indicators

Indicator Source Information NHS Date

Period Summary Hospital-Level Mortality

Indicator (SHMI)

This indicator measures whether the number of patients who die in

hospital is higher or lower than would be expected. This indicator is

not something that is collected for the Independent Healthcare

Sector.

Number of paedatric patients re-

admitted within 28 days of

discharge and number of adult

patients (16+) re-admitted within

28 days of discharge.

Sentinel Risk

Management System

which is used by all

BMI Healthcare

Hospitals

This figure provided is a

rate per 1,000 amended

discharges.

2011-2012

Percentage of BMI Healthcare

Staff who would recommend the

service to Friends & Family

BMI Healthcare Staff Survey NHS Staff

Survey 2015

Number of C.difficile infections

reported

Sentinel Risk

Management System


BMI Healthcare

Hospitals

This indicator relates to

the number of hospital-

apportioned infections.

April 2014 –

March 2015

Responsiveness to Personal

Needs of Patients

Quality Health


The responsiveness score

provided is an average of

June 2014 –

January 2015


2016

Report all categories applied to


questionnaires answered

by BMI Healthcare

inpatients.

Number of admissions risk

assessed for VTE CQUIN Data

BMI Healthcare only

collects this information

currently for NHS

patients.

April 2014 –

March 2015

Number/Rate of Patient Safety

Incidents reported

Sentinel Risk

Management System


BMI Healthcare

Hospitals

Based upon Clinical

Incidents with a patient

involved where the NPSA

Guidelines deem a

severity applicable.

October 2014

– March 2015

Number/Rate of Patient Safety

Incidents reported (Severe or

Death)

Sentinel Risk

Management System


BMI Healthcare

Hospitals

Based upon Clinical

Incidents with a patient

involved where the NPSA

Guidelines deem a

severity applicable.

October 2014

– March 2015

Indicator 1: N/A for independent sector

Indicator 2: Re-Admissions within 28 Days of Discharge (Adult)

The graph below indicates the re-admission rate to be 2.48. This compares favourably with the national

average of 10 cases per 1000 bed days.

Graph 20: Re-admissions

BMI Mount Alvernia considers that this data is as described for the following reasons:

o Each episode of re-admission is documented on an incident form and investigated in order to

identify any contributing factors, learning and consider recommendations for improvement

o Analysis over time is included within the quarterly and annual report Quality report


2016

Paediatric patients are not re-admitted as an emergency as the hospital does not have regular paediatric

staff on site.

Indicator 3: Percentage of BMI Healthcare Staff who would recommend the service to

Friends & Family

This data is taken from the recent BMISay Staff Survey which contained the mandated questions for the

FFT in line with NHS England.

Graph 21: Staff recommendations

BMI Mount Alvernia Hospital considers that whilst this data reflects above average score there is still an

opportunity for improvements in this area.

BMI Mount Alvernia Hospital intends to discuss the feedback from the recent staff survey ‘BMi Say’ at a

staff forum and agree the actions to be undertaken with staff to improve this percentage, and so the

quality of its services.


2016

Indicator 4: The number of C difficile infections reported

Graph 22: C.difficile

BMI Mount Alvernia Hospital considers that this data is as described due to our dedication to ensure a

safe environment in which to deliver a high standard of care.

BMI Mount Alvernia Hospital has a service level agreement with a Consultant Microbiologist who

provides advice on infection control issues, attends the Clinical Governance Committee and Medical

Advisory Committee (MAC).

BMI Mount Alvernia also has a dedicated infection control lead and link practitioners in department

areas who undertake regular audits locally. The dedicated team monitors and audit surveillance data,

reporting to the Clinical Governance Committee.

Indicator 5: Responsiveness to Personal Needs of Patients

Graph 23: Patient Satisfaction


2016

BMI Mount Alvernia considers that this data is as described due to the commitment of all staff to our

patients and the care in which they receive during every stage of the patient journey.

Indicator 6: Number of admissions risk assessed for VTE (Venous Thromboembolism)

Graph 24: VTE

BMI Mount Alvernia Hospital considers that this data is as described as per the findings of the clinical

VTE audit undertaken on a monthly basis. We also monitor VTE as a key clinical safety indicator under

the NHS Safety Thermometer.

A pre VTE risk assessment is undertaken for all cases of possible VTE. During the period April 2015 –

March 2016 BMI Mount Alvernia Hospital reported no incidents of preventable VTE.

Indicator 7: Number/Rate of Patient Safety Incidents reported

Graph 25: Patient Safety


2016

BMI Mount Alvernia Hospital considers that this data is on a par with the national average of reported

incidents, indicating a positive reporting culture alongside a commitment to ensure a safe environment in

which to deliver a high standard of care.

Initiatives to support the continued improvement of reporting incidents where there is no or low harm

includes:

o Training on induction

o Trigger lists to support departmental reporting

o Dissemination of analysis and learning through quarterly reports and newsletters

Indicator 8: Number/Rate of Patient Safety Incidents reported (Severe or Death)

Graph 26: Severe Incidents

BMI Mount Alvernia Hospital considers that this data is as described demonstrating our commitment to

our patients and our intentions to create a safe, effective and responsive environment. We aim to

maintain this measure by:

o Improving on the current robust process for patient safety incident reporting and management

including near misses

o Continuing to have in place a developing and systematic approach to shared learning

o Continuing to promote an open reporting and transparent culture.

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