Continuous Improvement - The Quality Route
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Introduction
Benenden Hospital is committed to the provision of a first class high quality service for its patients and their relatives. To ensure this occurs the hospital has developed a framework, which includes both internal and external mechanisms to deliver this high quality service.
Mechanisms both Internal and External to Deliver Quality at Benenden
Internal
1 Operational Plan and Key Performance Indicators
Benenden Hospital develops and implements an Operational Plan on an annual basis, designed to ensure that the hospital and its staff offer a high quality patient focused service through the continual review and improvement of patient facilities and the implementation of new services. It is the key to the success of any organisation, providing the opportunity to review progress made during the previous year, set out objectives for the current year and take stock of our current position.
2 Governance
The Governance principle supports the annual Operational Plan and is the corner stone of the hospital's commitment to quality. Governance at Benenden Hospital is the responsibility of the Hospital Director who has devolved its day to day management to the Director of Nursing, the Medical Director and the Governance Manager. The Governance Team, under the auspices of the Governance Manager, a Clinical Governance Committee and a Health and Safety Committee advise and assure the Board of Governors and the Hospital Management Board that effective and efficient systems are in place to protect the patient, the public and the staff and monitor standards. These Committees oversee a number of initiatives which go towards ensuring that the patient receives a high standard of care. These initiatives include:
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Patient Satisfaction Surveys, undertaken on an annual basis by an external provider with experience in the field of obtaining customer feedback.
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An annual multi - disciplinary Audit programme which seeks to improve the quality and outcome of patient care through peer review.
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Infection Control - To ensure that systems are in place that minimise the risk of patients and users of service acquiring infections during their stay in hospital. Ensuring that standards are maintained and monitored in line with policy. We have had no cases of cross infection related to MRSA in the last year.
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Incident Reporting - Benenden Hospital strives to achieve an open culture whereby anything that does not go according to plan is reported centrally, logged and monitored for trends. We use incident and near miss reporting to change and improve practice.
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Risk Management - A Risk Strategy reflects the hospital's commitment to providing a safe and secure environment for all and its intentions of achieving best practice with minimal risk and the resources available. It defines a proactive approach to risk management through the risk assessment process and governance committees and is supported by the incident and complaints management systems. This includes all risks whether clinical or non clinical, health and safety, fire, manual handling and occupational health.
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Complaints Management - The hospital recognises that complaints are an important learning tool as they offer valuable information about the patient experience. Comments and complaints are taken seriously and we endeavour to learn from them wherever possible and change practice accordingly. Reports are provided to the Board on a quarterly basis on statistical information and analysis.
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Hotel Services - Standards for environmental cleanliness at Benenden Hospital were developed to allow each department to have a copy and be aware of expectations. An audit process has also been developed and performance outcome monitoring will shortly be implemented in a programme of frequencies directly linked to the risk rating of each area. This will provide valuable feedback and allow us to improve where necessary. Benenden Hospital has corporate membership of the British Institute of Cleaning Sciences and we are able to train our staff on site ensuring professional skills are maximised. Our catering department have achieved a gold hygiene aware for excellence and the Heartbeat award for menu content. An a la carte menu is offered to our patients and delivered by catering staff who work locally with the wards and communicate directly with patients.
External Inspections
The hospital is registered by the Healthcare Commission and is inspected annually by qualified Inspectors. This inspection is based on a set of National Minimum Standards with which the hospital is required to comply. Inspections can be both announced and unannounced. The hospital would expect to receive one announced visit every year. Following each annual inspection a report is produced which once agreed is then available for public access through the Healthcare Commissions website. You can access our most recent report here|. In addition to our annual inspections, we maintain regular communication with the Commission.
Until recently the National Minimum Standards only applied to the Independent Healthcare sector. However the introduction of "Standards For Better Health" will replace the National Minimum Standards and will be applicable to all healthcare sectors. Benenden Hospital will, at the appointed time, develop a timetable to ensure migration from the National Minimal Standards to "Standards for Better Health".
The Hospital is also subject to inspections from the Health & Safety Executive and an inspection that took place in January 2005 resulted in some recommendations that the hospital is currently actioning.
As the hospital has recognised medical posts in Gynaecology we are also inspected by the Royal College of Obstetrics and Gynaecology on a regular basis.
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