1. Operations 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.
The Governance Framework supports the annual business 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 Patient Services, the Medical Director, Service Leads and The Patient Experience and Governance Lead. The Clinical Governance Committee meets quarterly and receives details of key performance indicators and a report from the Patient Experience and Governance Department, information from the Occupational Health and Safety Committee, the Information Security forum, the Infection Prevention and Control Committee and the Resuscitation Advisory Committee, to advise and assure the Board of Governors and the Hospital Executive 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:
- Patient Experience - Patients are invited to complete a patient experience card each time they attend the hospital, the information is collated and informs patient care going forward. The results are fed back to patients via The Patient Experience Boards which are located in each patient area.
- 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 - 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.
- 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.
- 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.
- 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 Management Board and the Clinical Governance Committee and also circulated to all consultants for information and required action. These indicators are monitored for trends and reflect clinician specialty 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 Clinical Governance Committee as appropriate.
3. Support Services
- Housekeeping –All staff are fully trained in the all aspects of cleaning within the hospital setting. The housekeeping staff work closely with the Infection Control and Prevention Team ensuring a high level of cleanliness is maintained within the hospital.
- To monitor the cleaning standards an auditing system is in place with the frequency of audit directly linked to risk rating in each area. Any improvements identified during an audit have a resolution time scale allocated depending in the risk nature of the issue identified.
- Catering - The Catering Department have achieved the Food Standards Agency, Food Hygiene Rating 5 and Healthy Eating Award, Tunbridge Well Borough Council.
4. External Inspections - CQC
The Hospital is registered by the Care Quality Commission. The Care Quality Commission is the independant 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 the 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 Hospital, Care Homes or anywhere else where care is provided. The Care Quality Commission, through their monitoring system ensure that the providers are meeting the required Standards of Quality and Safety.