in collaboration with

Clinical
quality

Bupa International

www.bupa.com
Pat i e n t s a f e t y
PS1 Safety Culture is at the heart of the organisation
The organisation states that it is committed to patient safety
There is not a published statement referencing patient safety
Patient safety is referenced in internal documents and materials
There are public statements relating to patient safety for example,
a patient charter
Patient safety is stated at the heart of all the hospital’s activities
for example, hospital mission statement
Hand hygiene is a priority
The hospital regards it as the staff’s responsibility to wash their hands
There are some posters and memory aids to encourage hand washing
Hand washing audits and inspections take place
Hand washing is facilitated by touchless taps, increased availability
of sinks, alcohol sprays available at every ward entrance and
disciplinary action for staff who do not comply
The organisation undertakes patient safety initiatives
Staff undertake patient safety initiatives on an ad hoc basis ✔
✔ The hospital fulfils any compulsory patient safety initiatives ✔
The hospital has a regular programme of patient safety which is
✔ funded and supported by management ✔
The hospital looks externally to accreditation bodies eg JCI, patient
✔ safety organisations eg IHI, and undertakes specific initiatives
eg WHO surgery checklist ✔
✔ The organisation collects information and uses it to improve
patient safety
✔ There is no organised system of collecting clinical indicators
✔ eg mortality rates, readmissions
Data from clinical indicators are collected  ✔
Analysis of data from clinical indicators is regular and leads to action for
✔ improvement ✔
The hospital compares its indicators to other like institutions and
contributes to regional, national or international databases on safety ✔
2
PS2 The organisation learns from mistakes it has made

The organisation has a mechanism for identifying near misses and
adverse incidents
There is occasional and ad hoc reporting of incidents
There is a system for reporting and recording adverse incidents, with
occasional staff training
Staff are actively trained and encouraged to report incidents,
and learning/change in practice occurs as a result of issue review
Staff performance is monitored to ensure they report relevant incidents.
When issues are reported they are fully investigated with detailed action
plans and changes in practice occurring as a result
Mistakes are analysed
Staff are expected to analyse the cause of their own reported mistakes ✔
Most mistakes are investigated by line management ✔
There is a system to ensure all mistakes that are reported undergo
✔ necessary analysis ✔
Incidents are triaged by a central office and those requiring it
✔ undergo full root cause analysis ✔
The organisation listens to patients who have a complaint
✔ There is not a formal process to record patient reported complaints

Staff are encouraged to report mistakes in a no blame environment

Some departments have procedures for patient reported complaints ✔
There are informal mechanisms to protect staff who raise issues ✔ There is a dedicated system throughout the hospital for patients to
report incidents, and these reports are reviewed internally  ✔
Staff are offered anonymity if requested ✔
Patients are actively encouraged to report mistakes, and these reports
‘No blame’ is guaranteed by established and documented procedures ✔ are always discussed as part of routine quality improvement and
The ethos of the hospital actively supports the raising of and feedback is given to the patient ✔
resolution of issues and discourages non-reporting ✔

3
PS3 The organisation identifies areas where mistakes could happen

There are dedicated resources for risk management activities
There are no formal risk management processes
Risk management activities are part of the responsibilities of the
quality team
There is a dedicated risk department 
There are separate risk departments for clinical and non-clinical issues
Staff are trained to identify and analyse risks
Staff are expected to know how to identify and analyse risk
Staff are encouraged to attend risk analysis courses
The hospital offers a cyclical programme of risk management training
All staff are trained in risk management as part of regular mandatory
training
Staff are empowered to act on identified risks
Staff members act if they see a risk ✔
Staff are able to report risks to senior management for action ✔
✔ Staff are given tools and resources to make changes where they
✔ have found risk ✔
Staff are fully supported by a dedicated risk team when an issue is
identified and needs action ✔
✔ There is a systemised and cyclical process for identifying risk
A risk is usually identified after an incident occurs
✔
The organisation looks proactively for areas where mistakes could
✔ happen as well as responding to mistakes that have happened  ✔
There is a formal annual risk identification exercise in the hospital
✔
There is a quarterly review within each department, supported by a
risk team to review possible risk areas and take action to prevent these ✔

4
PS4 There are systems to ensure everyone learns from each others mistakes

There are effective and tested communication systems
Communication between departments is informal and based on
individual interaction
There is informal sharing of information between departments
There is a central team which communicates relevant information
to all departments
There are regular meetings between the heads of each department
to formally share learning from incidents
There are appropriate opportunities to train staff on safety incidents
Staff are trained when time is available
✔ Staff are expected to learn as they go as part of their normal activities ✔
✔ Staff have annual sessions for training on incidents
✔
Staff have monthly sessions for formal training on safety incidents ✔
✔

5
PS5 The organisation identifies and has a focus on high risk processes and patients

There is an early warning system to identify individuals who are at
high risk.
Staff are aware of high risk patients as part of normal activities
High risk patients are prioritised during ward rounds and handover
The hospital uses an ‘early warning system’ to identify high risk patients  ✔
There is a dedicated team of individuals who visit every department to
implement processes to identify high risk patients and situations
There are policies to manage high risk patients and processes
High risk patients/processes are identified when they occur
✔ The hospital has a list of high risk processes, and there are
✔ procedures in place to identify high risk patients on admission ✔
All high risk patients and those patients undergoing high risk
procedures are identified on their person (eg colour coded
wristband); on their notes; on their bedside; and on any transfer
✔ from one department to another ✔
There is an audit of high risk patients/processes to ensure hospital
policies are followed and improvements are made where necessary ✔

6
PS6 Staff are always concerned about patient safety in their daily work

Staff members are involved in patient safety initiatives There is a disciplinary process for staff who do not adhere to
There is not a formal obligation for staff to get involved in patient the hospital’s policies, processes and standards relating to
safety initiatives patient safety

Staff are expected to undertake at least one patient safety

There is not a formal disciplinary process in place  ✔
initiative a year ✔ Individual departments can discipline staff who do not adhere to the

Staff are asked to prove involvement in a patient safety

hospital’s standards on patient safety  ✔
initiative during annual appraisal ✔ There are documented policies in place to deal with staff who do not

It is part of the job description and regular assessment of

adhere to these standards on patient safety  ✔
staff to initiate or get involved in several patient safety initiatives ✔ There are training programmes to educate all staff about how these
standards work in practice, which staff must attend if issues have

Staff have regular training on patient safety

been identified. ✔
There is no formal training on patient safety

There is informal and ad hoc training when a patient safety

issue has been identified ✔
There is a regular in hospital programme of patient safety training ✔
Staff have undergone external training on how to improve patient safety ✔

7
LEA D E R S H I P

LS1 Senior management understand and invest in safety and quality

Senior management are responsible for and measured on the safety Clinical issues form part of the agenda at senior management
and quality of the hospital meetings
Quality and safety are not managed by the senior management  Senior management meetings do not consider clinical matters

Quality and safety are routinely discussed in senior management Serious clinical incidents and professional issues are discussed ✔
meetings ✔ There is clinical representation at senior management meetings
Senior management prioritise safety and quality through to report on clinical matters ✔
investment and are measured on delivery ✔ Clinical outcome data, eg mortality rates, is routinely reported
There is evidence that senior managers are accountable for and discussed at every senior management meeting ✔
quality and safety matters ✔

Senior management appropriately prioritise investment based on

clinical need
Financial investment is decided with minimal clinical input

Funds are made available on an ad hoc basis when there is clinical need ✔
Clinical requirements are a core consideration in procurement activity ✔
Clinical and safety requirements are prioritised when planning budgets  ✔

8
LS2 There is a clear organisational structure

There is a well-structured and readily accessible organisational The management structure reflects the needs of the hospital and
chart patients
There is an informal, non-published, understanding of organisational There is no defined management structure
structure
The hospital has distinct managerial roles ✔
There is a basic organisational chart available if requested ✔ Clinical staff have roles in management to make sure clinical issues are
There is a complete organisational chart which is actively displayed in appropriately considered ✔
the hospital with named individuals ✔ Managerial staff support and develop clinical functions ✔
As well as a hospital-wide structure each department/ward has and
displays its own organisational chart for patients to see  ✔ The structure demonstrates accountability and authority
There is no clear organisational structure, and seniority is informally
Each staff member has a written job description which clearly understood
identifies roles and responsibilities
Job descriptions are not available
The structure demonstrates clear reporting lines ✔
It is clear who holds authority, and they are responsible for delivering
Most people have job descriptions although these do not contain
explicit details about roles and responsibilities
any required change ✔
All staff are accountable and their roles are clearly defined ✔
All staff have some form of job description ✔
Every member of staff has a standardised format of job description with
clear statement of expectations, roles and accountabilities ✔

9
LS3 There are appropriate committees for important aspects of quality

The hospital has the following committees:

(please tick all that apply)

Quality ✔
Risk Management ✔
Infection Control ✔
Research and Ethics ✔
Medical Advisory/Executive ✔
Patient Safety  ✔
Resuscitation ✔
Pharmacy/Medication Safety ✔
Mortality and Morbidity ✔
Clinical Practice Guidelines ✔

10
LS4 The clinical structure is organised in such a way to make sure patients are kept as safe as possible
There is an identified clinical lead (Medical Director or Nursing
Director) that provides hospital-wide clinical supervision
There is no identified clinical lead
The hospital has either a medical director or a nursing director
The hospital has both a medical director and a nursing director
The hospital has both a medical director and a nursing director,
plus another clinical lead eg chief pharmacist
There is a qualified clinical manager for each clinical department
There is no qualified clinical manager in each department
There is a clinical manager at directorate level
There is a clinical manager at departmental level
There are clinical managers at ward level
The clinical leaders have the necessary training and experience
No extra training or experience is offered
Leaders are encouraged to undertake extra training in their own time ✔
Leaders are given in hospital training programmes to support them ✔
Leaders are funded and given time to undertake external training
programmes ✔
✔
Clinical policies and procedures guide the provision of care
There are informal policies and procedures where required
Each department is responsible for creating and maintaining its
✔ own policies and procedures  ✔
✔ All clinical policies and written procedures, used to manage care, are
documented, with clear ownership and review dates, and made
✔ available for all to use (eg via intranet) ✔
Audit takes place to ensure compliance to policies; and that
review/updates are carried out on time ✔
11
LS5 The hospital operates under national/local legal and regulatory requirements

Designated individuals make the organisation aware of legal
requirements
There are no designated individuals to identify legal requirements 
Legal compliance is identified as part of job description for certain
staff members
Leadership is informed when legal/regulatory requirements are
not met
There is not a clear mechanism to inform senior management when
there is a potential legal issue 
✔ Members of staff know who to report legal and compliance issues

There is a dedicated team, with legal representation, to identify

to and are expected to do so when necessary ✔
requirements and monitor compliance ✔ There is a clear reporting mechanism for such issues and staff

There is a dedicated team with supporting individuals at departmental

are actively encouraged to do so ✔
level ✔ There is an ongoing programme and continual review of existing processes
to ensure compliance and any required action is taken and legal/regulatory
requirements are met ✔

Changes are made to ensure legal compliance in a timely manner

It is the responsibility of the individual who notices the issue to rectify
the problem  ✔
Compliance/legal fulfilment is managed centrally ✔
There are timeframes for response to issues and they are adhered to ✔
The legal/regulatory departments regularly assess national and
international changes  ✔

12
LS6 The leadership of the organisation emphasises ethical care

There is an ethics committee guided by strong written practices
There is no formal ethics committee
There is an existing ethics committee which meets on an ad hoc basis
The ethics committee considers all matters concerning research
and development
All research undergoes ethical approval
Ethical approval is not mandatory for any research or experimental
treatments undertaken in the hospital
✔
Any research or experimental treatment requires ethical approval ✔
✔ All research requests are considered by an ethics committee at

The scope of the ethics committee extends to all clinical activities

formal meetings ✔
undertaken in the hospital ✔ Requests for research are forwarded to the ethics committee for formal
approval, and doctors who are found to be carrying out experimental
treatments without approval are investigated and disciplined where
There is an easy and clear mechanism to bring ethical issues
forward for consideration
required ✔
There is no published list of issues that require ethical approval

The hospital publishes a list of clinical scenarios where ethical approval

is required ✔
There is an ethics committee in place, and staff bring issues to the
committee ✔
The ethics committee pro-actively identifies areas which need ethical
approval ✔

13
LS7 There is multi-disciplinary and collaborative management of patients
The hospital understands the concept and benefit of multi-
disciplinary teams
The doctors are in charge of the patient and all other clinical staff
must obey their orders without challenge
It is recognised that doctors, nurses and other clinical staff all
have an important role to play in each patient’s management,
and this is formally recognised
There are formal multi-disciplinary team meetings on a regular
basis to discuss particular cases
Cases requiring multi-disciplinary teams are identified where
possible prior to admission and are subject to regular review
and monitoring
Junior members of staff are able to challenge senior members of
the team
The senior doctor is in charge of the patient and challenge would be
✔ inappropriate
Junior doctors (and other staff) are free to discuss cases openly with
senior doctors ✔
✔ There are formal meetings between all clinical staff to discuss patients
and their care  ✔
✔ Junior staff are confident to challenge and escalate issues above and
beyond the doctor in charge of a patient if required ✔
✔ Oncology patients are all subject to multi-disciplinary review
There is no multi-disciplinary function in oncology 
The importance of multi-disciplinary management is recognised when
considering care plans ✔
Most oncology patients are managed by multi-disciplinary teams with
review at formal multi-disciplinary meetings ✔
All oncology patients are managed by multi-disciplinary teams and
reviewed at multi-disciplinary team meetings ✔
14
Foc u s o n Q u a l i t y

FQ1 The hospital manages clinical services to ensure unnecessary tests and interventions are not
undertaken

There is a use of clinical pathways
Clinical pathways are not used
Clinical pathways are used in some disciplines
Clinical pathways are used in all disciplines
Clinical pathways are used in all disciplines and the number used is
increasing for all procedures, and formally reviewed on, at least,
an annual basis
Over intervention or unnecessary tests are identified, investigated
and challenged
Doctors are in charge of treatment and are not challenged on their practice
✔ 
Regular audit of doctors practice is done to monitor variation ✔
Audit is undertaken, and doctors are challenged if they are thought to
be over-investigating or over-treating ✔
Audit is undertaken, doctors are benchmarked against each other

There is the use of order sets

and clinical pathways and unwarranted variation are challenged ✔
Order sets are not used

Order sets are beginning to be introduced in some areas

Staff understand and believe in the use of order sets to rationalise

the investigations and treatments that take place, and these are in
place for most common conditions ✔
Order sets are a functional part of everyday working and are
embedded in each clinical department ✔

15
FQ2 There is use of medical evidence at the core of all functions

The hospital considers medical evidence in the development of
policies and procedures
Where the hospital has policies and procedures these are written
by the departmental staff
There are documented policies and procedures which make some
reference to relevant research
All documented policies and procedures have a section which lays out
the evidence that was considered when formulating the document
There is constant and cyclical review of policies and procedures to
ensure they are in line with the most recent evidence on the subject
Medical evidence is sought from a variety of sources to inform
best practice
The hospital relies on local best practice to develop policy ✔
The hospital uses recognised, national research to determine practice ✔
The hospital uses international research, adapted to local needs,
✔ to determine practice ✔
The hospital uses international research to determine practice
✔ but gives more importance to large cohort trials, randomised
controlled trials and systematic review papers
✔

There is on-site access to current evidence and research such as

published papers, research organisations, or international authorities
Staff are expected to use their own resources to access medical literature

Staff are provided with online access and log ins to research databases ✔
There is an onsite library with current journals, books and online access ✔
Staff are given formal training in how to consider medical evidence
through the hospital’s library ✔

16
FQ3 The hospital works on always trying to improve its quality

The hospital undertakes a regular quality audit program
Audit is not routinely undertaken 
Each department is expected to undertake a regular, ie annual,
documented audit of some aspect of its practice
Audit of clinical quality is core to the hospital’s function and staff are
actively encouraged to undertake independent audit projects
There is an organisation-wide system to implement quality
improvement solutions
Quality improvement is everyone’s responsibility but not formally
managed
✔
Each department is responsible and accountable to improve its quality ✔
✔ There is a central quality office which supports and oversees every

There is a centralised audit office which supports and oversees each

department in quality improvement ✔
department in relation to the regular audit ✔ A central quality office enables departments to meet with each
other to share knowledge and experience to improve quality delivery ✔
Designated staff and management meet on a regular basis to plan
actions based on results of the quality audit
No formal meetings are undertaken

Clinical and managerial staff meet annually to discuss audit findings,

with some resulting in action

Clinical and managerial staff meet quarterly to discuss audit results

and action plans are made and documented at every meeting ✔
Audit occurs on an on-going basis and each audit undertaken is
not complete until actions have been taken as a result

17
FQ4 The system supports staff to improve quality

Staff are encouraged to suggest quality improvement ideas Staff receive training on the importance and techniques of quality
Staff are commended when/if they raise or suggest a quality improvement
improvement initiative No training is given

All clinical staff are given time and resources to undertake quality Staff are given access to in-house training programmes (voluntary) ✔
improvement initiatives ✔ Funds and resources are made available for staff to access appropriate
It is in the job description and accountabilities of all members of staff external training resources in quality improvement  ✔
to participate in at least one quality improvement initiative a year ✔ All clinical staff members are required to undertake training in quality
Staff are incentivised to complete quality improvement initiatives improvement as part of their job ✔
and roll these out across the hospital ✔

Staff members of all levels are involved in the development and

implementation of solutions
Doctors are involved in quality improvement initiatives ✔
Both doctors and nurses are regularly involved in quality
improvement initiatives ✔
Every member of staff (including admin and support staff) are
actively involved with quality improvement initiatives  ✔
Staff are rewarded for successful implementation of an initiative
which can demonstrate an improvement in patient care ✔

18
FQ5 There is a regular measure of patient satisfaction which leads to action

Patient satisfaction is measured on a regular basis Patient responses lead to implemented solutions where problems
Patients share feedback to the hospital if they wish to do so ✔ are identified

There is a small sample (less than 10%) of patients surveyed for

Patient feedback is reviewed on an ad-hoc basis ✔
satisfaction Patient satisfaction information is analysed and occasionally
action is taken as a result
There is a large sample (over 30%) of in-patients surveyed for
satisfaction Satisfaction scores are analysed at departmental level and each

In-patients and out-patients are all surveyed as part of the process.

department makes action plans accordingly  ✔
Visitors and relatives may also be included ✔ Satisfaction scores are fully analysed at a departmental and organisational
level. Organisational change can also occur as a result of feedback  ✔

19
FQ6 Dealing with complaints

Patients are informed of the complaint process Data from complaints is used to improve services provided to
There is no formal complaint process in place patients

There is a formal complaint process which patients can have access

Patient complaints sometimes lead to change ✔
to if they request ✔ Complaints are handled at a local level and departmental managers
are responsible to initiate change if a requirement is identified
Patients are made aware of how to make a complaint at both
admission and discharge ✔ Complaints are handled by a central department in conjunction with
the area concerned. Action plans are agreed and implementation is
Patients are actively encouraged to give constructive feedback, as
monitored ✔
all feedback is regarded as beneficial to quality improvement ✔
There is a regular communication of significant complaints to all
staff in the hospital so that they are all aware of the issues raised,
Patient complaints are handled in a confidential manner, with
how they were resolved and what changes need to be implemented
established timelines
across all areas of the hospital ✔
Complaints are handled as and when they can be (informal) ✔
Patients are given written assurance about confidentiality and
informed about expected timeframes for a response ✔
There is a specific department which deals with complaints, and
the patient is kept updated throughout the process ✔
Complaints are triaged into different categories and there are
established and documented processes and timelines for
investigation and response ✔

20
FQ7 The hospital monitors and analyses the results of its treatments given to patients

The hospital monitors key clinical indicators Deaths within 30 days of an emergency admission
(please tick all that apply)
Deaths within 30 days of a routine admission
Unplanned readmissions ✔
Mortality in infancy ✔
Unplanned return to theatre ✔
Falls ✔
Unplanned critical care admission ✔
Proportion of patients treated according to clinical guidelines ✔
Serious complaints ✔
Incidents of drug allergies ✔
MRSA infections ✔
Prescription errors ✔
C.difficile infections ✔
Surgical site infections ✔ Clinical indicators are analysed and reported on in a regular cycle
Unplanned transfers out of hospital ✔ There is no formal means of collecting or analysing data from
clinical indicators
Mortality rates ✔
It is up to each department to identify and record their own data
Complications ✔
from clinical indicators ✔
Cases of DVT ✔
There is a central department responsible for supporting and governing
Death within 48 hours of anaesthetic ✔ each department in collecting and analysing data from clinical indicators ✔
Deaths from all cancers The hospital continually reviews and increases the number of
indicators it monitors. Results are analysed and action taken ✔

21
FQ7 (Continued)

The hospital benchmarks itself on clinical indicators against peer The hospital measures Patient Reported Outcome Measures
institutions (PROMs)
There is no benchmarking activity The hospital is not aware of PROMs

The hospital is involved in a programme of benchmarking against The hospital is aware of PROMs but they are not used
local hospitals, if available ✔ PROMs are used in some departments in the hospital ✔
The hospital benchmarks clinical indicators on a local and/or
PROMs are widely used and are a core way of measuring activity
national level, if available ✔ in the hospital ✔
The hospital benchmarks clinical indicators on a local, national
and/or international level ✔

There is a process to urgently act when clinical indicators identify a

serious issue
Clinical indicators are not used to identify issues

Clinical indicators are regularly monitored to identify urgent issues,

and these are dealt with as they arise ✔
There is a dedicated department that continually monitors clinical
data and has a written process for acting on urgent issues ✔
The system of data analysis is stringent and there is a system to identify
and mitigate potentially serious issues before they become a real danger ✔

22
FQ8 Experimental treatments are only undertaken in a safe and regulated environment

The hospital makes efforts to stop clinicians from performing Patients are informed about and sign their consent to participate
unregulated research in research
The clinician has responsibility for the treatment given to the patient If research does not require explicit consent it is not requested of
and is not regulated the patient

There is a hospital policy which requires any research to go through It is not mandatory to request consent although generally patients
appropriate approval first ✔ are asked to give it 

There is a random audit and inspection of clinician’s work to ensure
unregulated treatments are not occurring
Alongside random audit and inspection, key areas involved in research
are subject to higher scrutiny e.g. pharmacy, laboratory, radiology
All patients involved in research are required to give written consent ✔
There is a special consent form for individuals undergoing experimental
treatments which ensures all the possible risks and benefits have
✔ been discussed thoroughly prior to treatment starting ✔

Data from experimental treatments is shared with the larger health

care community
Information is not shared outside the hospital

Information is shared with local facilities and practitioners ✔

Information is shared with local and national facilities and practitioners ✔
Information is shared with local, national and international facilities
and practitioners ✔

23
C l i n i c a l S e rv i c e s

CS1 The patient is identified correctly and the correct procedure is done

Patients are identified correctly
Patients are usually identified by name alone
Patients are required to wear an identification band at all times
which includes name and one other key identifier (date of birth
or hospital number)
Two chosen patient identifiers are used on every document relating
to that patient
The hospital uses an electronic system for patient identification
Before any invasive investigation/procedure a patient identification
check is performed
An informal check is performed
A single member of staff checks the patient identification label
✔ More than one member of staff check the patient, the site, and
the procedure  ✔
✔ No significant procedure can take place until an appropriate checklist
✔ has been filled in to ensure correct patient, site and procedure ✔

There are processes to highlight similar sounding patient names

There is no process in place

Staff are told verbally at handover of patients with similarly

sounding names

Patients with similar sounding names have a bright marker or other

obvious indication put on their clinical notes

Patients with similar sounding names are identified on their clinical

notes and separated within wards to minimise potential mistakes ✔

24
CS2 Staff communication is conducted in a way to provide the best care

There is dedicated time for handover between clinical teams There is regular audit of legibility of notes, records and
There is no handover of patients between nursing shifts prescriptions
Notes are not regularly audited
There is informal handover between shifts as appropriate ✔
There is a dedicated 30 minute handover period between nursing shifts
A small sample of notes is audited (less than 10%) ✔
A large sample of notes is audited (over 25%)
There is a dedicated handover period between nursing shifts of
more than 30 minutes ✔ The legibility of notes is regarded as a key clinical indicator which
undergoes continual monitoring ✔
There are policies in place regarding verbal/telephone
pharmaceutical orders All investigations ordered have a clear written clinical rationale
There is no formal policy  When specified investigations are ordered, clinical justification is
not required
There is a general policy relating to verbal/telephone orders ✔
There is a policy which clearly defines exactly what can and cannot
All radiology and laboratory requests contain clinical justification ✔
be ordered over the telephone ✔ Order sets are used for routine procedures, but clinical justification
is required where an order set is not used
No routine pharmaceutical orders can be taken over the telephone ✔
Investigation requests are recorded with clinical justification, audits
are undertaken and the results are used to review individual practice
and ensure compliance ✔

25
CS3 There is safe and efficient use of medicine

Medication use complies with legal and regulatory requirements
Medication use is the responsibility of the prescribing doctor
It is the responsibility of the pharmacy to ensure legal and regulatory
compliance
There is a documented set of policies which governs the use of
medicines within the hospital
The pharmacy has an automated system of requisition and
✔ dispensing
Manual processes are in place for drug requisition and dispensing
There is some use of an automated system in the hospital pharmacies ✔
There is a fully automated system to manage requisition and dispensing
of drugs supply

There is a specific pharmacy committee which meets regularly to review There is an automated system which additionally identifies out of/nearly
current information on appropriate usage, legal and regulatory issues  ✔ out of date medicines, high demand, and high risk medications

Every effort is made to use medicines safely and report medication

incidents
It is up to each individual to report any medication incidents ✔
There is an established system of reporting medication incidents or near
misses which staff are aware of ✔
Staff are given regular training on how to avoid medication error  ✔
The hospital undertakes external initiatives to improve its medication safety
record (eg nurses wearing high visibility apron when on dispensing round
 ✔

26
CS4 The organisation minimises its risk for infection.

There is a formal Infection Control committee The building is designed to minimise infection
There is no such committee Infection control is regarded as an important issue for the hospital ✔
There is a committee which meets at least twice a year  There is a dedicated infection control committee which gets involved

The committee contains representatives of the hospital staff and

in planning and maintenance of buildings ✔
external clinical representation  There are dedicated positive and negative pressure rooms and theatre

The hospital employs full-time staff who serve as permanent member(s)

suites available for infected patients ✔
of infection control committee  ✔ The hospital has a proven track record of low infection rates compared
to national averages ✔
Staff are engaged in on-going infection control programmes
Staff are free to engage in infection control activities as they choose Monitoring of hospital acquired infections is performed
Irregular and informal monitoring happens
Staff work to minimise infection by attending training courses 

Annual appraisal and performance review takes into account staff

Each department tracks its own infection rate record ✔
compliance with infection control measures and training attendance ✔ There is a central department which collates and governs each
departments infection data ✔
It is mandatory for all staff to attend infection control training programmes ✔
The hospital publishes for external consumption its infection rates and
benchmarks itself against comparable hospitals ✔

27
CS4 (Continued)

The hospital tests for infections before admission

There is no testing of patients prior to admission

There is testing of patients who have recently been treated in hospital

All patients are tested for infection at admission ✔

All patients are tested prior to admission ✔

28
CS5 Medical records are well-maintained, secure and available

There is an organised patient medical records system
There is a medical record for all in-patients but not all out-patients 
A written medical record is kept for every individual admitted by the
hospital for a minimum of 10 years
The medical records department is safe and secure whilst being
accessible
There is not a dedicated medical records department
✔ There is a records department which is lockable and alarmed

A written medical record is kept for every individual admitted by the There is a records department which is manned 24 hours a day and
hospital for a minimum of 10 years, and medical records are consistently facilitates access to all professionals who need to access records ✔
structured and kept in a confidential and secure location ✔ All records are kept electronically on a secure, backed up server
There is an electronic medical records system that is safe and secure

Medical records are audited for completeness, signing and dating

There is no regular audit of these details

There is a small sample (less than 10%) audited for these three variables ✔
There is a large sample (over 25%) audited for these three variables

The records are kept electronically and there is therefore no issue with
illegibility and identification of entrant

29
CS6 Patients are informed and involved in every stage of their care.

Written information is available to patients about their medical Patients are informed and can exercise choice when consenting to
condition their treatment
Some information is available at patient’s request  ✔ The doctor decides what is the best treatment for the patients without
input from the patient ✔
Information leaflets are available in clinical areas for patients to read ✔
The consent form includes a section to show alternative treatment
Patients are given written information about their particular condition
options have been discussed with the patient ✔
when they visit the hospital ✔
Patients are advised of how to obtain a second opinion prior to
Patients are given information about external organisations that may
be able to provide them with additional information and support about
agreeing to treatment  ✔
their condition ✔ The hospital provides patients with outcome data on their particular
condition compared to peer hospitals ✔
Patients undergoing tests/procedures provide written consent
Consent is usually obtained in written format ✔ Information is communicated in a manner and language that is best
for the patient
There is one standard consent form always used ✔ It is up to the individual clinician to speak to the patient appropriately ✔
There are different consent forms for adults/children/tests/procedures,
which are regularly audited
Patient’s communication needs are documented in the medical record ✔
Any significant information (eg pharmacy prescriptions) or diagnoses can also
Particular attention is paid to the consent process and patients are
given full written information about possible risks and complications
be provided in a written format in the language of the patient’s choosing ✔
prior, which is recorded, to signing consent form ✔ Cinicians have access to support staff eg translators or religious
personnel if required ✔

30
CS7 Nursing and medical assessments
All assessments are performed in a timely manner
Assessments are expected to happen soon after admission to the hospital ✔
Medical and nursing assessments are delivered in a standardised
format (eg proforma)
The hospital sets a target time for assessments to happen after
admission. Medical and nursing review assessments should happen
at least once a day when patient is admitted
There is regular audit of how quickly and regularly assessments are done
with resultant action where there is lack of compliance with target times. ✔
Nursing assessments take into account the holistic and social care
needs of the patient
Social care needs are considered on an ad hoc basis
It is expected that every patient will have their social, religious and
cultural needs assessed as part of the original nursing assessment
There is a standardised form for assessment which has a section on
social care, religious, and cultural requirements of the patient which
must be completed
There are separate (non-nursing) dedicated staff to assess the social
care needs of the patients
Medical assessments take full medical history and examination
into account
It is the doctor’s responsibility to include what they feel necessary in
the medical assessment ✔
✔
It is expected that every doctor will take into account a full medical
history and examination of every patient ✔
✔ There is a standardised form that doctors are expected to fill in when
first assessing a patient, which includes medical history and examination ✔
There are different forms for different specialities which aid the doctors
in making the correct and most relevant assessment possible ✔
There is a system to double check medical assessments by senior staff
✔ Patients are usually assessed by a junior doctor (eg Resident Medical
Officer) only 
✔ Where a patient is initially assessed by a junior doctor it is expected that a
senior doctor will assess them as well ✔
There is an established system in the hospital which ensures that every patient
✔ is seen by their overseeing senior doctor within 24 hours of admission  ✔
Medical assessments are audited on a regular basis to identify issues
✔ and training/action is given ✔
31
CS8 The clinical laboratories process specimens accurately, safely and in reasonable time

There are systems in place to ensure specimens are correctly Specimens are processed in an appropriate environment
identified and not lost The laboratories are off-site, and it is their responsibility to maintain
Specimens are labelled with at least 2 patient identifiers ✔ their equipment ✔
There is a paper based tracking system for all specimens received by the Some laboratory services are outsourced, with a formal service level
laboratories ✔ agreement in place ✔
There is a computerised (bar coded) labelling system for all specimens All laboratory services are provided in house and undergo regular
received by the laboratories ✔ external inspection ✔
The overall process is supported by regular auditing ✔ All laboratory services are provided in house and have undergone
independent accreditation, eg ISO ✔
All specimens are processed in an appropriate timeframe
Specimens are processed as quickly as possible  ✔ There is a system for ensuring laboratory results are double checked
Some results are double checked if necessary ✔
There is a system of triage for urgent, semi-urgent, routine specimens ✔
There are written, agreed and reasonable timeframes for processing
There is regular audit of accuracy of machines in the laboratories ✔
specimens ✔ There is an established system of notifying doctors of urgent or highly

The laboratories are measured for service delivery and accuracy

important results  ✔
against specified timeframes ✔ All histopathology specimens are double checked by a senior doctor ✔

32
CS8 (Continued)

Specimens are stored and disposed of safely

Laboratories are expected to store and dispose of their specimens safely ✔

There are dedicated colour coded bins for different risk specimens, with
locked temperature controlled storage facilities ✔
The hospital’s infection control department inspects the laboratories to
ensure maximum safety  ✔
The laboratories undergo external inspection and/or accreditation
(eg ISO) ✔

33
CS9 Radiology services are safe, accurate, timely, and appropriate to patient need

Patients have timely access to any radiology service they
require (plain X ray, CT and MRI) – all patients will have routine
examinations in the timeframes outlined below
within within within within within within within more than
4 hours 6 hours 12 hours 24 hours 48 hours 1 week 2 weeks 2 weeks
X-ray ✔
CT ✔
MRI ✔ radiology reports (especially mammograms and oncology examinations)
There is a system to ensure that reports are accurate and
double-checked
There is no structured system for double checking radiology reports
A small percentage (less than 25%) of radiology reports undergo internal
double checking
A large percentage (over 25%) undergo internal double checking ✔
The hospital uses an external, independent company to double check

Investigations are performed in an environment safe to staff,

There is a system to ensure only necessary investigations are
patients and visitors
performed
Radiation warnings are posted at the entrance/exit of the department  ✔ Investigations are ordered at the discretion of the doctor ✔
Multilingual signs advise of radiation warnings, including specifically for
All radiology requests have a written clinical reason/justification for the
pregnant women ✔ request  ✔
All staff who work in the radiology department wear radiation tags
The hospital uses a system of clinical pathways to manage the number
that are audited in line with local requirements ✔ of investigations performed ✔
A radiation safety committee is in place to ensure that all staff undergo
There is audit of radiology utilisation, with resultant action to reduce
regular safety training and that all services/buildings are designed with
the number of unnecessary tests done ✔
radiation safety in mind ✔

34
CS10 Surgery and Anaesthesia are undertaken in the safest environment possible
Anaesthesia is performed in a controlled, appropriately staffed, safe
environment
It is the anaesthetist’s responsibility to ensure everything is safe
And the theatre suite has dedicated anaesthetic support staff (e
operating department practitioners), and segregated anaesthetic rooms
And anaesthetic drugs, equipment and safety devices are checked by
two individuals prior to every operating list 
And specialised anaesthesia (eg paediatric) is only performed by
anaesthetists with relevant qualifications
Pre-surgical checks are comprehensive and ensure right patient,
right procedure, right site
Pre-surgical checks are performed by nursing staff in a verbal
(non-written) method
There is a written verification for every patient undergoing surgery to
ensure correct operation is being done on the correct person
The hospital uses a dedicated proforma which checks patient
identification, patient consent, and surgical site marking
The hospital uses an external tool, such as the World Health Organisation
Surgical Safety Checklist or equivalent system developed by the hospital ✔
Infection control is prioritised for surgery
Infection control is a routine part of any surgical intervention ✔
✔ Clean and dirty cases are separated on the operating schedule  ✔
The hospital uses measures to avoid surgical infections including
✔ prophylactic antibiotics, laminar flow and positive pressure rooms ✔
The infection control department is involved in the design, up keep
✔ and regular inspection of the operating suites ✔
There is appropriate, safe provision of post surgery care
Patients undergo recovery in the operating theatre and are immediately
transferred back to the ward
There is a dedicated recovery area with a staffing ratio of less than
1 nurse to 2 patients ✔
There is a dedicated recovery area with a staffing ratio of more than
1 nurse to 2 patients ✔
The hospital has documented policies and procedures for the provision
✔ of safe post surgery care, including checklists and other tools where
appropriate. ✔
35
CS10 (Continued)

Any surgery undertaken is appropriate, rationalised and necessary Operating theatres and associated services maintain a system of
Surgery and the procedure that is undertaken, is dependent on the tracking activity for audit purposes
doctor’s clinical judgment  ✔ There is a hand written log book in each theatre to record the details

Clinical pathways and protocols are employed/used during the

of every operation performed ✔
assessment/diagnostic process to help physicians decide who should There is a computerised log book in each theatre to record the details
and should not have surgery  ✔ of every operation performed ✔
There are case conferences and multi-disciplinary team meetings to decide There is a computerised (bar coded) system to identify instruments and
which patients should and should not have surgery for specified procedures ✔ consumables used in case of surgical error ✔
The head of the surgical directorate analyses individual surgeon’s The hospital uses an external company to regularly audit theatre
utilisation rates and challenges individual doctors if necessary ✔ activity to ensure maximum safety ✔

Day case procedures or lower lengths of stay are utilised where

appropriate
Length of stay is at the doctor’s discretion ✔
There is a dedicated day surgery unit  ✔
The hospital has a published list of procedures that should be done as
a day case, and any variation from this is investigated  ✔
The hospital audits its length of stay for surgical patients routinely and
compares this to other local hospitals ✔

36
CS11 Resuscitation
There is appropriate training of all staff in resuscitation techniques
and procedures
Staff are expected to have an understanding of resuscitation techniques
All clinical staff are given training in basic life support (BLS) by the
hospital on an annual basis
All staff (both clinical and non-clinical) are given training in basic life
support (BLS)
All relevant clinical staff are given advanced training in life support
techniques as required eg ILS, ATLS, ACLS, PALS 
There are dedicated teams available for resuscitation
Resuscitation is carried out by the staff on the ward
The hospital has a dedicated resuscitation department where patients
are taken for specialist support
The hospital operates a code blue or similar system with a dedicated
response team (including anaesthetists and CPR specialists)
The hospital uses an early warning system to identify and manage
patients who are at high risk of requiring resuscitation
There are specific guidelines regarding how, when to, and when not
to resuscitate
✔ Staff are expected to know resuscitation techniques on their own
There are posters and signs available to remind staff of the resuscitation
✔ protocol in all clinical areas ✔
There is a system whereby patients can issue “Do Not Resuscitate”
✔ instructions, and staff are aware of instruction ✔
The hospital monitors changes in international guidance on resuscitation
✔ and implements any changes in the hospital ✔
Resuscitation trolleys are adequately provided, stocked and
✔ checked
The ratio of resuscitation trolleys to beds is less than 1 trolley to 24 beds ✔
The ratio of resuscitation trolleys to beds is more than 1 trolley to 24 beds ✔
Each resuscitation trolley is accompanied by a dedicated defibrillator ✔
✔ All resuscitation trolleys are checked for stock and contents every day
and a log book is kept with the trolley ✔
✔
37
M a n a g e m e n t o f s ta f f

MS1 The hospital checks all aspects of an employee’s background that could affect patient care

All staff are checked for criminal and legal convictions There is verification of the qualifications of all other clinical staff
There is no set mechanism for checking the background and qualifications (nurses, physiotherapists etc)
of staff There is not a formalised process for verifying clinical qualifications

Staff are asked to declare any criminal or legal convictions ✔ Clinical staff are asked to produce copies of their original certificates

All clinical staff undergo routine checks for criminal and legal convictions
and qualifications before employment ✔
The hospital conducts primary source verification for a proportion
All staff (both clinical and non-clinical) undergo routine checks for
of clinical staff
criminal and legal convictions 
The hospital conducts primary source verification for all clinical staff ✔
There is verification of a doctor’s qualifications
There is not a formalised process for verifying doctor’s qualifications 

Doctors are asked to produce copies of their original certificates and

qualifications before employment/granting of admission rights ✔
The hospital conducts primary source verification for a proportion
of doctors

The hospital conducts primary source verification for all doctors ✔

38
MS2 The hospital recruits and retains the best staff

Personal development and education is actively supported The hospital is recognised as a good employer
It is the responsibility of the staff to cater for their own educational and The hospital deems itself to be a good employer  ✔
developmental needs
The hospital demonstrates a low staff turnover as recognition it is a
The hospital has dedicated facilities for staff support which may good employer ✔
include a dedicated HR department, library and online access to
Staff satisfaction surveys are carried out and actions are taken as
educational materials ✔ a result  ✔
The hospital provides a regular, structured education programme for
There is external recognition eg awards for being a good employer ✔
all clinical staff ✔
The hospital makes dedicated funds available to pay for staff members
to access external training courses ✔

There is a proactive recruitment programme for senior doctors

The hospital relies on its reputation to attract the best senior doctors ✔
The hospital actively markets itself as a good place to work for senior
doctors ✔
The hospital board reviews its requirements for senior doctors on a regular
basis and targets specific doctors to come and work at the hospital ✔
The hospital uses an external recruitment company to recruit the
best senior doctors, in some cases internationally

39
MS3 The hospital ensures that every staff member receives an orientation/induction

Attendance at induction is prioritised and enforced Induction includes all aspects important to the member of staff’s
There is not a formal induction programme everyday work
The induction is structured and includes (please tick all that apply):
All clinical staff are expected to attend formal induction training, and a
register of attendance is kept  ✔ Patient safety ✔
All staff (both clinical and non clinical) are expected to attend formal Manual handling/lifting techniques ✔
induction training, and a register of attendance is kept ✔ Fire safety ✔
Induction is organised and carried out by a dedicated in house team ✔ IT systems ✔
Radiology requests/results ✔
Laboratory requests/results ✔
Occupational health ✔
Senior executive structure ✔

40
MS4 The hospital looks after staff that inspire better care

Improving services provided to patients is a core part of each staff

member’s ongoing assessment
Staff are not assessed on quality improvement initiatives

It is a formal part of annual appraisal to look at any quality improvement

initiatives that staff members have participated in ✔
Staff are given dedicated time each week, away from clinical activities
to be involved in clinical improvement/audit work ✔
There is a programme for staff to suggest quality initiatives which is
centrally coordinated ✔

41
MS5 Staff are offered access to occupational health

The hospital understands the health needs of its staff Occupational health offers the following services:
Each member of staff is expected to look after their own health ✔ (please tick all that apply)

There is a dedicated occupational health service available to all staff ✔ Hepatitis B immunisation for high risk staff  ✔
Each member of staff is expected to fill out a pre-employment health Hepatitis B immunisation for non high risk staff as well 
questionnaire. ✔ Psychological services ✔
The hospital makes special provision for staff with disabilities to be able
to work in hospital and pro-actively manages health and wellbeing for
Absence management services ✔
employees ✔ Hepatitis C immunisation programmes

HIV testing programmes

Stress and bereavement counselling  ✔

Annual health checks ✔
Flu vaccinations, if appropriate ✔

42
MS6 Staff undergo a regular documented appraisal and assessment of capabilities

All staff undergo annual appraisal There is a process to ask clinical staff to prove their stated
Appraisal is undertaken informally on an ad hoc basis capabilities
There is no such process in place 
All clinical staff undergo formal annual appraisal by their line manager
Staff are asked to produce certificates/written evidence of courses/
All clinical staff undergo formal annual appraisal by their line manager
and through peer review  ✔ training/exams they have undertaken ✔
Appraisal includes techniques such as 360 degree feedback and patient Staff are examined by peers on their medical and surgical techniques ✔
feedback  ✔ Staff can be asked to undergo external examination if competency is
called into question ✔
Appraisal of clinical staff takes into account the following
(please tick all that apply)

Clinical competence ✔
Clinical indicators eg morbidity/mortality rates ✔
Communication skills ✔
Ability to get on with colleagues  ✔
Quality improvement initiatives ✔
Log book of activity (including number of patients seen and hours worked) ✔
Absence record ✔
On-going training/courses/exams undertaken ✔

43
MS7 There is a system to identify and deal with poor performing individuals

Poor performing individuals are readily identified

Poor performance is typically identified by colleagues 

Poor performance is identified at an annual appraisal

There is a structured, anonymous system whereby staff and patients

can alert senior management about issues with their colleagues

Line managers continually monitor poor performance and service

delivery ✔

44
E n v i ro n m e n t a n d e q u i pm e n t

EE1 The hospital building and utilities are maintained to a high standard

The cosmetic aspects of the hospital are regularly maintained and There is capacity to appropriately cater for the volume of patients
refurbished Inpatient Occupancy is (please tick)
Refurbishment happens only if there is a problem
100%
There is a central department dedicated to buildings maintenance that
80% ✔
responds to requests for refurbishment ✔
60%
There is an on-going cyclical programme of refurbishment and
maintenance ✔ 40%

The hospital undergoes, external, independent check of the cosmetic 20%

appearance of the hospital (can include response to patient comments)  ✔ 0%

The utilities eg electricity and water are reliable and constant

The utilities are checked if a problem occurs

There is a regular programme of inspection and testing of utilities supply ✔

As well as a regular programme of testing, there is a separate water

storage tank dedicated to the hospital and a separate generator for
emergency electricity ✔
There is more than one water tank and/or generator eg dedicated
generator for theatres and ICU ✔

45
EE2 The hospital provides a safe environment for all staff, patients, and visitors

The buildings are planned and assessed to minimise hazards and The hospital has the capability to move patients and equipment
risks quickly
The hospital will make necessary changes if an incident happens Because of the nature of the building moving patients and equipment
can sometimes be tricky
There is a central department that actively looks at the building to
identify and deal with risks  ✔ The hospital has a dedicated portering department  ✔
There is a clear process for any member of staff to report a possible risk The hospital is designed with wide corridors, lifts and communal areas
to the central buildings department ✔ to facilitate safe movement ✔
The hospital uses an external company with expertise in risk The hospital has invested in advanced technology to facilitate transport
management to assess its building around the hospital. ✔

46
EE3 The environment of the hospital is conducive to care and well-being for all

Religious beliefs are catered for Patients and visitors can navigate around the hospital easily
Patients may practice whatever religious or cultural practices they wish Patients/visitors are expected to ask for directions if they get lost
in the hospital ✔ There are adequate signs and maps displayed throughout the hospital ✔
There are specific food menus which cater for different religions
Different clinical areas are designated by colour coded schemes which
eg kosher or halal  ✔ facilitate navigation
Segregated prayer rooms for different religions are provided within the
There are dedicated members of staff whose sole job it is to guide
hospital  ✔ patients/visitors, signs are multilingual ✔
There is provision of dedicated pastoral care for the major religions
eg rabbi, imam, priest etc ✔

47
EE4 Waste management ensures no unnecessary contamination or hazards

Waste is segregated according to type All sharps are disposed of in a safe manner
(please tick all that apply) Sharps disposed of in clinical waste ✔
General waste ✔ Dedicated sharps boxes available in some clinical areas

Confidential paper waste ✔ Dedicated sharps boxes available in all clinical areas ✔
Non-hazardous clinical waste ✔ Dedicated sharps boxes available throughout and kept at a height that

Hazardous clinical waste ✔

is out of the reach of children ✔
Recyclable materials ✔ Waste is cleared on a regular schedule
Radioactive waste ✔ Less than every 2 days

Every 2 days
Hazardous materials are handled and disposed of safely and
Once a day
accordance with guidelines
Staff are advised to take extra precautions with hazardous materials ✔ More than once a day ✔
There are general written protocols and procedures for disposing of
hazardous waste ✔
As well as general written procedures, specific processes available for
chemotherapy, radioisotope, and hazardous chemical storage and disposal ✔

The hospital goes above national regulations for hazardous waste

management in order to protect its staff and patients even further ✔

48
EE5 The right services/equipment are available and maintained to meet patient needs

Clinical support services are available to meet patient need Processes are in place to enable care if required services/treatment
(please tick) are not available on-site

Offsite Offsite with Onsite Onsite with

It is recommended to the patient that they go to an alternative hospital ✔
with no maximum with no maximum
Plans are made as required to bring the necessary equipment in electively
maximum waiting maximum waiting
waiting times waiting times  ✔
times published times published
published published The hospital has written agreements with appropriately equipped local

Outpatient hospitals to transfer the patient if required ✔

pharmacy
✔
The hospital is a tertiary referral centre itself and has comprehensive
Radiology ✔ equipment in all specialties ✔
Laboratory ✔

All equipment undergoes testing according to manufacturer’s or

regulatory requirements
Equipment is tested if an error occurs

The hospital usually follows the manufacturer’s recommendations on

equipment maintenance ✔
The hospital adheres to national regulatory requirements for equipment
maintenance ✔
The hospital has a dedicated devices and equipment department that
proactively looks for equipment that needs attention ✔

49
EE6 The hospital is fire safe

Everything is done to minimise the fire hazards in all areas Adequate equipment is fitted to deal with a fire, including:
There is fire fighting equipment available in some areas ✔ (please tick all that apply)

The hospital adheres to national regulatory requirements on fire hazard ✔ Fire extinguishers ✔
There is a central hospital department which proactively looks for Sprinkler system ✔
and deals with fire risks in the hospital ✔ Centrally controlled fire alarm ✔
The hospital uses an external company which specialises in fire safety
to identify fire hazards
Dedicated fire alarms in high risk areas eg ICU, theatres, electrical rooms ✔
Smoke alarms ✔
In case of fire all staff are trained to keep themselves and patients Heat sensors ✔
safe
Staff are expected to make themselves knowledgeable about fire safety
There is quick and easy access for external fire services
There is dedicated fire safety training at induction The nearest fire station is within 30 minutes

There is dedicated fire safety training at induction and on an annual basis✔ The nearest fire station is within 15 minutes

At least once a year there is an unannounced fire safety drill to test staff The nearest fire station is within 5 minutes ✔
There is a dedicated fire station/engine onsite 

50
EE7 The hospital is dedicated to the security of all

There are trained, professional security staff available to suit the Extra security measures are in place for high risk areas:
size and opening hours of the hospital (please tick all that apply)
There are no dedicated security staff 
No Electronic Dedicated CCTV
additional pass (for alarm
Security staff are available 24 hours a day  ✔ measures controlled
drugs – double
Available 24 hrs at a ratio of 1 to 100+ patients key)

Available 24 hrs at a ratio of more than 1 to 100 patients ✔ General

pharmacy
✔ ✔
Controlled
Patients feel safe and secure about their belongings drug ✔
cupboards
Patients are expected to keep their belongings safe and secure at all times ✔
Maternity
Inpatients are provided with security lockers located centrally  unit ✔
Laboratories ✔
Inpatients with secure lockable cabinets by their beds ✔
Theatres ✔
The hospital takes legal and financial responsibility for the security of ICU ✔
patients’ belongings

51
EE7 (Continued)

All staff members are immediately identifiable, and their

movements can be traced
Staff are not expected to wear photo ID 

Staff are expected to wear photo ID at all times ✔

As well as photo ID, swipe access is required for all clinical or sensitive
areas, eg patient records, computer rooms, etc.

The hospital uses an advanced system eg thumb print access, for access
and security  ✔

52
EE8 The hospital has a disaster plan

The hospital has documented procedures, processes and policies

for disasters of any type
There is limited disaster planning in the hospital

There are disaster plans for major emergencies eg fire, earthquake etc ✔
The hospital has additional documented procedures for other disasters
such as pandemic ✔
The hospital tests its disaster plans with scheduled acted out scenarios ✔

53
Bupa International
Global Purchasing &
Provider Management
Russell Mews, Brighton
Sussex BN1 2NR
United Kingdom

Tel:
+44 (0) 1273 866430

Email:
quality@bupa-intl.com

© Bupa 2010

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