1. Operations plan and key performance indicators
Benenden Hospital develops and implements an operational plan on an annual basis, designed to ensure that our hospital and staff offer 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 Quality Strategy supports the annual business plan and is the cornerstone of our commitment to quality.
Governance at our hospital is the responsibility of the Hospital Director who has devolved its day-to-day management to the Director of Clinical Services, Clinical Governance Lead, the Medical Director and service Leads.
Our Quality and Safety Committee meets quarterly and receives details of key performance indicators and a report from our:
- Product Selection Group
- Infection Control Committee
- Radiation Protection Committee
- Occupational Health and Safety
- Resuscitation Advisory Committee
- Endoscopy User Group
- Medical Gas Committee
- Information Governance Forum
- Cyber Security Forum
These Committees advise and assure the Board of Governors and Hospital Executive that effective and efficient systems are in place to protect the patient, the public and the staff and monitor standards.
They oversee a number of initiatives which go towards ensuring that our patients receives a high standard of care. These initiatives include:
Patient experience
Patients are invited to complete a patient experience survey each time they attend our hospital. This information is collated and informs patient care going forward. The results are fed back to patients via the patient experience boards located in each patient area.
Audit
An annual multi-disciplinary audit programme which seeks to improve the quality and outcome of patient care through peer review.
Infection control
Our infection control team is committed to the development and maintenance of a safe environment for patients, staff and visitors.
Incident reporting
We strive 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.
Risk management
A risk strategy reflects our hospital's commitment to providing a safe and secure environment for all and its intentions of achieving best practices 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 incident and complaints management systems.
This includes all risks whether clinical or non-clinical, health and safety, fire, manual handling and occupational health.
Complaints management
We recognise 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 Hospital Executive on a quarterly basis, based on statistical information and analysis.
If you have a complaint or concern, please contact us through our complaints procedure.
Clinical indicators
Identified and agreed clinical indicators are collected and collated on a monthly basis by the Governance team and are included in the quarterly reports provided to the Hospital Executive and the Quality and Safety Committee. They are also circulated to all hospital Consultants for information and required action.
These indicators are monitored for trends and reflect clinician speciality and performance. Indicators currently collected include:
- Unplanned re-admissions
- Day case conversions
- Returns to theatre
- Transfer of care
- Reported clinical incidents
- Reported non-clinical incidents
- Number of serious untoward incidents
- Number of written complaints
- Medication incidents
- VTE assessments
- Surgical Site Infections
This list is reviewed by the Quality and Safety Committee as appropriate.
3. Support services
Housekeeping
All staff are fully trained in all aspects of cleaning within the hospital setting. Our Housekeeping staff work closely with our Infection Control and Prevention Team, ensuring a high level of cleanliness is maintained within our hospital.
To monitor the cleaning standards, an auditing system is in place with the frequency of audits directly linked to risk rating in each area. Any improvements identified during an audit have a resolution time scale allocated depending on the risk nature of the issue identified.
Catering
Our Catering department has achieved the Food Standards Agency Food Hygiene Rating 5 and Healthy Eating Award, Tunbridge Wells Borough Council.
4. External inspections - CQC
Our hospital is registered by the Care Quality Commission. The Care Quality Commission is the independent regulator of all Health and Adult Social Care in England. The Commission promotes the rights and interest of people who use the services and have a wide range of enforcement powers to take action on users' behalf if services are failing.
The aim of the Care Quality Commission is to make sure better care is provided for everyone, whether in hospitals, care homes or anywhere else where care is provided. The Care Quality Commission, through its monitoring system, ensure that the providers are meeting the required Standards of Quality and Safety.