Patient Safety and Quality

Westside Private Hospital’s Commitment to Patient Safety and Quality

Westside Private Hospital is committed to providing the highest quality healthcare, with a core focus on each patient’s experience. Providing the safest possible care whilst achieving patients’ desired outcomes is reflected in our:

Day-to-day operations
Corporate and clinical governance
Support systems in place for our clinicians, nurses and broader workforce
Workplace culture and values

The Nexus Hospitals Group is the national healthcare provider we are owned and operated by. We utilise Nexus’s robust Quality Management System (QMS) and clinical governance framework to manage the care and services we provide.

Nexus Hospitals’ QMS is designed to monitor care outcomes, patient satisfaction and safety initiatives, manage and mitigate risks, and identify training requirements for our staff across the National Safety and Quality Health Service Standards. This system is supported by continual investment in state-of-the-art medical equipment and a highly skilled team of clinicians, nurses and support staff. All Nexus Hospitals perform various audits for compliance as per our accreditation and licensing requirements.

We report on a variety of quality scorecard indicators including:

Patients’ experience and feedback
Hand hygiene compliance rates
Surgical site infections
Fall rates
Medication safety
Unplanned returns to theatre

At all times we uphold the National Safety and Quality Health Service Standards (NSQHS) – the national benchmark that all hospitals Australia-wide must meet to maintain their licensing and accreditation status. Learn more about our approach to the National Standards below and how we implement Nexus’s QMS and clinical governance framework to deliver quality healthcare locally.

Westside Private’s Approach to the Eight National Safety & Quality Health Service Standards

1. Clinical Governance

Westside Private Hospital gathers important data across all aspects of our hospital to continuously improve the safety, effectiveness and quality of our services. We use clinical governance systems across all levels of our organisation to achieve, monitor and regularly review our safety and quality performance.

Our entire workforce have accountability to patients at Westside Private Hospital and the broader community for ensuring our healthcare is safe, high quality and continuously improving. That is our commitment.

2. Partnering with Consumers

Westside Private Hospital partners with select consumers and patients as this has proven beneficial in the planning, design, delivery, measurement and evaluation of our hospital. We place great importance on these partnerships as they help to guarantee quality patient outcomes and safety standards, whilst also benefiting patients’ carers and families, our clinicians and more broadly the healthcare industry. These partnerships exist across the following three levels:

1. The relationship between Westside Private’s clinician and patient at the point of care; a relationship founded on our values of respect and collaboration, commitment to excellence, patient focus and innovation.

2. Patients, carers, families and consumers’ involvement in planning, implementing and evaluating change at the department level.

3. Consumers or patients’ involvement in the governance, policy and planning of our healthcare service. Key areas of focus at this level include patient safety, facility design, quality improvement, patient or family education, professional development, ethics and research. Partnerships with the broader community may also occur at this level.

3. Preventing & Controlling Infections

Westside Private Hospital has robust systems in place to mitigate the risk of infection, foster good antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources.

We know the best way to stop germs from spreading and have best practice measures in place to support this, particularly with hand hygiene, sterilisation techniques and the use of protective equipment. Our facility is well-maintained and optimised for patient flow. Our systematic approach to preventing, controlling and responding to infections creates a safe environment for all visitors and staff at our facility.

4. Medication Safety

Medicines are the most widely prescribed treatment in healthcare and contribute significantly to improvements in patients’ health when used appropriately.

Accurately and safely prescribing, dispensing and administering the appropriate medicine to patients and monitoring medicine use is a mandatory standard at Westside Private Hospital. Our clinicians’ duty of care ensures patients and consumers are informed about and understand their individual medical needs, and associated risks.

Before commencing an episode of care, Westside Private Hospital will source a patient’s best possible medication history and have this on record. We ask patients for full disclosure about their medical history, current medications, allergies and adverse drug reactions in our patient admission form. Our nurses ensure patients are discharged with all the necessary information including scripts to care for themselves once home.

5. Comprehensive Care

Westside Private Hospital provides continuous and collaborative care to patients in partnership with their healthcare team, carers and families. Our hospital has integrated systems in place supporting our clinicians to deliver comprehensive, quality healthcare whilst mitigating and managing the risk of harm.

All clinicians at our hospital undertake a screening and assessment process with patients to identify potential risks that could be associated with the delivery of healthcare. Patients, their carers and families are consulted as part of this process to develop goal-oriented, comprehensive care plans.

If a patient is at risk of harm, our clinicians will deliver targeted, best-practice strategies to prevent and manage this from occurring. Safely managing transitions between episodes of care, and ensuring a continuum of comprehensive care are standards our clinicians abide by.

6. Communicating for Safety

One of the best ways we coordinate safe patient care as well as visitor and workforce safety is through communication and documentation. This includes communication with our patients, carers and families, multidisciplinary teams and clinicians, and all business units across our organisation.

Effective communication and documentation help to mitigate high-risk situations and manage patient safety. Westside Private has formal processes in place to identify patients, match care to their needs, and appropriately manage clinical handovers when information about a patient’s care emerges or changes.

Whilst there are times when communication (be it informal) in the delivery of patient care will not be recorded, our hospital’s approach is always to formalise the communication and documentation requirements critical to patient safety at key times during the delivery of care.

7. Blood Management

Westside Private Hospital uses a combination of clinical governance and quality improvement systems when managing a patient’s own blood, as well as any blood or blood products.

As part of the Nexus Hospitals group, we have strategies and procedures in place to accurately manage the availability and safety of blood and blood products. Safety systems are in place and every care is taken to safely administer blood products to patients, and closely monitor and report any adverse reactions or incidents. This dual approach to blood management and patient care is the most effective way to ensure the appropriate and safe use of blood and blood products at our hospital.

8. Recognising & Responding to Acute Deterioration

All medical and support staff at Westside Private have a duty of care to recognise and promptly respond to changes in a person’s physiological, cognitive or mental state, otherwise known as acute deterioration. Providing patients with appropriate and timely care is part of our organisation-wide recognition and response system when acute deterioration is identified.

Early detection is critical in these situations as it may improve outcomes and lessen the intervention required when treating the patient. At Westside Private Hospital we understand the importance of identifying and acting on the warning signs of clinical deterioration efficiently and appropriately. Management of these circumstances draws on our approach to comprehensive care and communication and documentation for safety.

Having a highly-skilled healthcare team who understand the signs and symptoms that could signal acute deterioration, combined with our safety, quality and patient monitoring systems all help to recognise acute deterioration.

Westside Private Hospital’s Latest Patient Safety and Quality Management System Report

Westside Private Hospital measures quality in many areas, by analysing and reporting on outcome and process measures, patient satisfaction and the hospital quality ranking.

Our core, quality principle is the continuous improvement of all processes and services supporting the care of patients. The Quality Management System (QMS) implemented across our hospital group allows us to deliver consistent and comprehensive care to patients.

As part of the Nexus Hospitals group, Westside Private Hospital monitors and reports on many quality measures, including patient satisfaction surveys and patients’ experience, infection prevention and control, including hand hygiene compliance, patient incidents, medication safety and unexpected returns to theatre. The policies, processes, and procedures associated with these areas are embedded in all hospital operations and workflow. Quality management focuses on continuous quality improvement as measured by consumer and patient satisfaction. Our quality structure is unique: it is integrated and further strengthened by our highly-trained nurses and medical staff.

Westside Private Hospital Clinical Indicators

Patients Experience- Feedback
Infection Prevention
Monitoring incidents
Medication safety
Return to theatres monitoring

Patient Satisfaction & Experience

We never stop caring about patient care. That’s why we continually monitor and assess everything we do, so we can improve the quality of care we provide. Patient feedback plays a crucial role in maintaining and enhancing the quality of care provided at Westside Private Hospital. By actively listening to our patients, we gain valuable insights into their experiences, allowing us to make informed decisions about how to improve our services. Our quality outcomes are reviewed by our Medical Advisory Committee (MAC) before being made available for consumer feedback.

We encourage patients to confidentially share their thoughts through a post-operative survey sent via email. This continuous process of collecting and reviewing feedback ensures that we remain responsive to the needs and expectations of our patients, aligning with the National Safety and Quality Health Service (NSQHS) Standards.

Net Promoter Score

One of the key metrics we use to gauge patient satisfaction is the Net Promoter Score (NPS).

The NPS is a simple way to measure how happy our patients are with the care they have received. At Westside Private Hospital, patients are asked: “How likely are you to recommend our hospital to friends and family if they needed similar care or treatment?”
Patients rate this on a scale from 0 to 10, with:

• 10 being ‘extremely likely’ and
• 0 being ‘not likely at all’
Scores of 9 or 10 are considered “promoters” (very happy patients), 7 or 8 are “passives” (neutral), and anything below 7 is a “detractor” (unhappy patients). The NPS is calculated by subtracting the percentage of detractors from the percentage of promoters.

According to global NPS standards, an NPS score over 70 is considered very high and shows the service is world-class. From January to March 2025, Westside Private Hospital achieved a Net Promoter Score of 78.

Some of the more detailed results from patient feedback during this period revealed:

• 98% of surveyed patients expressed satisfaction with the quality of care received
• 97% praised our staff’s communication
• 98% felt safe whilst in our care

Net Promoter Score -78
(Jan-Mar 2025)

Quality of Care
(Jan-Mar 2025)

Staff Communicated Well
(Jan-Mar 2025)

Felt Safe in Hospital
(Jan-Mar 2025)

Infection Prevention

Westside Private Hospital follows strict infection control procedures. Our staff take every precaution to prevent infections and our antibiotic usage is monitored against best practice. As most patients are discharged the same day, we try to get feedback from your specialist or GP if any infections occur. We encourage you to contact us directly if you have any concerns regarding this.

Westside Private Hospital employs a variety of strategies to prevent infections. These include:

• auditing how often and how well staff wash their hands using soap and water or hand sanitiser
• using gloves and specialised sterile equipment
• using specialised disinfectants when cleaning facilities
• following national guidelines for high-level disinfection and sterilisation processes
• placing hand sanitiser dispensers in public areas throughout our hospital so that they are readily accessible to staff, patients and visitors.

During January to March 2025, Westside Private Hospital was honoured to care for 2850 patients. Through the diligent efforts of our doctors, staff, patients and visitors, we are proud to report zero post-surgical infections and an 87% compliance rate in hand hygiene.

Patient Outcomes
Post-Surgical Infections
(Jan-Mar 2025)

Monitoring incidents & near misses

Patient Falls

Patient falls are a leading cause of injury in hospitals and can extend or complicate a patient’s stay. Falls can occur when patients are weakened by illness, surgery, or accidents. Westside Private Hospital has robust measures in place to create a safe environment where the likelihood of patient falls is minimised. From January to March 2025, we cared for 2850 patients, none of whom experienced a fall whilst in our care.

Pressure Injuries

Also known as bedsores, pressure injuries occur when prolonged pressure damages the skin, ranging from redness to ulcers. Patients who are elderly, bedridden, have mobility issues, or chronic conditions like diabetes are more vulnerable. Pressure injuries often develop on hips, heels, tailbones, or other bony areas. At Westside Private Hospital, we use a variety of methods to both prevent and treat pressure injuries, and our target is always zero pressure injuries.

Patient Falls
(Jan-Mar 2025)

Medication Safety

Safe medication management is important to us at Westside Private Hospital. There are many systems in use throughout the hospital to support and promote safety in supplying and administering medications and monitoring their effects.

Staff at Westside Private Hospital follow strict guidelines to ensure that all medications are administered appropriately and accurately. Should errors in medication administration occur, they are captured in our hospital’s incident reporting system and investigated.

Of the 2850 patients we cared for from January to March 2025, there was one medication error that did not cause harm.

Medication Safety (Jan-Mar 2025)

Unexpected Return to Theatre

An unexpected return to the operating theatre is a serious event that may occur if complications arise after surgery. This can happen for various reasons, including infections, bleeding, or other unforeseen issues. At Westside Private Hospital, we have thorough processes in place to prevent these occurrences and deliver the highest standard of care for our patients. From January to March 2025, we cared for 2850 patients, none of whom needed to return to theatre after surgery.

Westside Private Hospital’s Commitment to Patient Safety and Quality

We report on a variety of quality scorecard indicators including:

Westside Private’s Approach to the Eight National Safety & Quality Health Service Standards

Westside Private Hospital’s Latest Patient Safety and Quality Management System Report

Westside Private Hospital Clinical Indicators

Net Promoter Score

Net Promoter Score -78(Jan-Mar 2025)

Quality of Care(Jan-Mar 2025)

Staff Communicated Well(Jan-Mar 2025)

Felt Safe in Hospital(Jan-Mar 2025)

Patient OutcomesPost-Surgical Infections (Jan-Mar 2025)

Patient Falls (Jan-Mar 2025)

Medication Safety (Jan-Mar 2025)

Unexpected Returns to Theatre(Jan-Mar 2025)

Why Patients ChooseWestside Private

Learn more about Westside Private Hospital...

About Us