BMI ROSS HALL HOSPITAL QUALITY ACCOUNTS APRIL 2014 MARCH 2015

Transcription

1 BMI ROSS HALL HOSPITAL QUALITY ACCOUNTS APRIL 2014 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 Hospital Information BMI Ross Hall Hospital in Glasgow is part of BMI Healthcare, Britain's leading provider of independent healthcare with a nationwide network of hospitals & clinics performing more complex surgery than any other private healthcare provider in the country. Our commitment is to quality and value, providing facilities for advanced surgical procedures together with friendly, professional care. BMI Ross Hall Hospital, aim is to provide the highest standards in all aspects of patient care. This includes ensuring unequalled attention to hygiene and involving patients in the process to minimise any risks of infection. The hospital has 101 ensuite rooms each with bathroom, telephone and television. It has four operating theatres, one minor procedures theatre, a high dependency unit/ five bed intensive care unit, a day chemotherapy unit and an endoscopy unit. The hospital offers an extensive range of treatments, including cardiothoracic, colorectal, cosmetic, gastroenterology, orthopaedic surgery, plastic surgery and general surgery. Ross Hall Hospital sees both inpatients and outpatients and offers a paediatric service as required. 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. This specialist expertise is supported by caring and professional medical staff, with dedicated nursing teams and Resident Medical Officers on duty 24 hours a day, providing care within a friendly and comfortable environment.

4 The building is situated within a residential area of Glasgow, with parking available on site, close to public transport and local amenities. The hospital cares for PMI and Self Pay Patients with a small number of NHS Spot contracts on request frm the local NHS Board. % of NHS patients to Ross Hall Business Row Labels Sum of cases % of cases NHS % Private % Grand Total % BMI Healthcare are registered as a provider with Healthcare Improvement Scotland (HIS) under the Health & Social Care Act BMI Ross Hall Hospital is registered as a location for the following regulated services:- Treatment of disease, disorder and injury Surgical procedures Diagnostic and screening Termination of Pregnancy Healthcare Improvement Scotland carried out an unannounced inspection on 7 th and 8 th April 2015 and assessed the service against all five quality themes related to the Healthcare Improvement Scotland (requirements as to independent healthcare services) regulations and the National Care Standards. Healthcare Improvement Scotland also considered the Regulatory Support Assessment (RSA) and used this information when deciding the frequency of inspection and the number of quality statements inspected. Based on the findings of this inspection, BMI Ross Hall Hospital was awarded the following grades: Quality Theme 0 Quality of information: 5 - Very good Quality Theme 1 Quality of care and support: 5 - Very good Quality Theme 2 Quality of environment: 4 - Good Quality Theme 3 Quality of staffing: 5 - Very good Quality Theme 4 Quality of management and leadership: 5 - Very good

5 Ross Hall 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 analyses trends and ensure that the quality improvements are operationalised. There has been development of information sharing and best practice. 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 in line with reporting requirements for Healthcare Improvement Scotland, Health Protection Scotland and Insurers BMI is a founding member of the Private Healthcare Information Network (PHIN) UK as a Scottish site we do not currently contribute to this initiative as it is not recognised by HIS.The BMI Ross Hall website gives patients information to help them choose or find out more about an independent hospital including the ability to search by location and procedure. 1. Safety 1.1 Infection prevention and control The focus on infection prevention and control continues under the leadership of the Group Director of Infection Prevention and Control and Group Head of Infection Prevention and Control, in liaison with the Infection Prevention and Control Lead for Ross Hall Hospital We have had: -

6 MRSA bacteraemia cases/100,000 bed days MSSA bacteraemia cases /100,000 bed days E.coli bacteraemia cases/ 100,000 bed days cases of hospital apportioned Clostridium difficile in the last 12 months. SSI data is also collected and submitted to Health Protection Scotland for Orthopaedic surgical procedures. Our rates of infection are; Orthopaedic Surveillance Number of hip replacements 96 Number of knee replacements 89 Number and details of infections hip and knee replacements 0 High Impact Intervention Care bundles have been implemented in clinical areas for Hand Hygiene, PVC, CAUTI, and clinical areas record their compliance and audit details on a monthly basis. BMI Learn offers mandatory training with blended modules that include a face to face practical session for hand hygiene, aseptic non touch technique and other infection prevention activities. The site Infection Prevention and Control Link in conjunction with the Practice Education Facilitator and Regional Trainer offer focused training sessions for newly recruited staff to ensure appropriate foundations are established within the induction period.

7 Environmental cleanliness is also an important factor in infection prevention and our patients rate the cleanliness of our facilities highly. 1.2 Assessment of the Care Environment 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. Senior Management team participate in Leadership Walk rounds which provide the opportunity to observe and analyse the clinical areas and provide staff with opportunity to discuss areas of concerns and provide suggestions for improvement in processes. The Infection Prevention and Control Lead undertake regular environmental audit of all clinical areas in conjunction with the ward and housekeeping staff, using the Health Protection Scotland Quality Improvement Tool. Clinical staff undertake self-audit of compliance with daily, weekly and monthly cleaning schedules. We have a Patient Participation Strategy and our Patent Focus Group receive feedback at each meeting regarding the progress with audit and any upgrades or refurbishments to our clinical environment. 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, Ross Hall 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. 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 98% compliance with the Risk Assessment process. In a bid to improve and maintain these results our VTE Champion has undertaken additional training and support for staff whilst undertaking the audit and provides feedback to departments on individual performance, addressing any shortcomings identified. Ross Hall 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.

8 0.012 PE (Rate per 100 admissions) Effectiveness 2.1 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

9 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 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

10 At Ross Hall Hospital we continue to embed the principles of the Enhanced Recovery Programme with collaborative working with our consultants and physiotherapy team as well as our nursing teams. Year to date average AVOL for Total Hip Replacements= 3.6d NHS and 4.1d PMI; and for Total Knee Replacement 3.9d NHS and 2.8 PMI. Our corporate Integrated Care Manager analyses and reports site compliance on these results monthly. Ross Hall has an Enhanced Recovery Programme Group led by the Director of Nursing and attended by representatives from areas across the hospital. A current review and revision of Pre-operative Assessment Services and Ambulatory care is underway to improve service provision and assist in managing patient expectation. There is a lead physiotherapist for ERP who has initiated local training sessions for staff to raise awareness and there is a group currently working on patient information provision. 2.2 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. These are closely monitored and reported through the internal incident reporting system and investigated accordingly with action plans formulated in response to lessons learned and Consultants and staff spoken to as necessary

11 Unplanned Readmission within 31 days (Rate per 100 Discharges) Unplanned return to theatre (Rate per 100 Theatre Cases) Unplanned Returns to theatre and readmission within 31 days are discussed within Clinical Incident review and Lessons Learned Forms and fed into the Clinical Governance Committee Recurring themes are analysed and managed appropriately with Consultants meeting with the Executive Director and Director of Nursing. 3. Patient experience

12 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. Of an Annual response rate of 4723 the patient responses in each category as a %- Average Impression of Admission Average Impression of Consultant Average Impression of Nursing Average Impression of Accomodation Average Impression of Catering Average Impression of Discharge Average Impression of Quality of Care Average of How likely to recommend to Friends and Family Complaints In addition to providing all patients with an opportunity to complete a satisfaction survey BMI Ross Hall 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

13 Stage 3: Patients can refer their complaint to independent adjudication if they are not satisfied with the outcome at the other 2 stages. The main themes of complaints are around billing issues, communication and managing patient expectation and environmental issues related to the fabric of the estate. Our Patient Services Department work closely with the hosptial teams to provide support. Our Patient Services Laision officer visits patients within the ward to receove direct feedback on performace and what we can learn from patient experience and this has had positive benefit in faciitating early ressolution and prevention of escalation to the formal stage. At any time service users can contact Healthcare Improvement Scotland at Gyle Square I South Gyle Crescent Edinburgh EH12 9EB Tel no The graph above evidences the decrease in number of written complaints received by Ross Hall Hospital in recent years.. In undertaking investigation of and response to complaints we ensure that we can demonstrate lessons are learned and action plans agreed to demonstrate our commitment to continuous quality improvement. Our Lessons Learned session are attended by departments across the hospital and staff can gain insight and engage in valuable learning from incidents in a bid to reduce recurrence in the future. Lessons learned from other sites and facilities will enhance this learning experience. 4. Non-Mandatory Quality Indicators

14 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. Action Plans Reflective Accounts and statements are uploaded to the system as evidence of closing the loop. 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.

15 Our Pharmacy Department participate in a full suite of audit activities looking at antimicrobial prescribing, prophylaxis prescribing, missed doses audit, controlled drug audit, and are supported by the BMI policies and procedures under the supervision of the Group Chief Clinical Pharmacist

16 Whilst there appears to be an upward trajectory of incidences this is recognised as improved reporting and improved data quality and greater interdepartmental working with an absolute focus on clinical governance and safety.

17 5. Research No patients were recruited to take part in research. 6. Priorities for service development and improvement Cancer Services The development of Cancer Services is a key stategic driver this fiscal year with significnat improvments in process across areas of the business. The organisation has recently achieved the Macmillan Environment Award for the work undertaken to ensure the environment is conducive to standards of excellence. Review of the terms of reference to ensure robust Multi Disciplnary Team Review is undertaken within all key tumour groups continues with the developent of the Cancer Services Improvement Group. Critical Care Critical Care services have been reviewed and the hospital now benefits from 24 hour Tier 2 RMO Intensivist Cover and 24 hour Consultant Anaesthetist Intensivist cover to ensure standards of critical care are achieved and the hosptial has a robust system for identifying the deteriorating patient and can implemtn early intervention. Capsular Endoscopy The Capsular Endoscopy Service is now fully implemented with patients benefiting form this minimally invasive procedure. A Specialist Nurse has been developed to lead the service and develop service enhancements going forward.