Patient Safety and Quality - Westside Private Hospital

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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

 

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


The Montserrat Day Hospital 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 Montserrat 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 Montserrat’s QMS and clinical governance framework to deliver quality healthcare locally.

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

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 – nurses, clinicians, management, the board of Directors and support staff 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.

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, integrity, collaboration, innovation and compassion.

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 focused on 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.

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.

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 Online Health Assessment to be completed at least three days before admission. Our nurses ensure patients are discharged with all the necessary information including scripts to care for themselves once home.

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.

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.

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 Montserrat Day Hospital 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.

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 Patient Safety and Quality Management System (QMS) Quarterly Report: April to June 2024

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 Montserrat Day Hospital 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 rates, patient incidents, medication safety and return to theatre percentiles. 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

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.

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 receive. At Westside Private Hospital, patients are asked: “How likely are you to recommend our hospital to friends and family if they need 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 patient). 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 April to June 2024, Westside Private Hospital achieved a Net Promoter Score of 72. 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
  • 96% praised our staff’s communication
  • 98% felt safe whilst in our care

Quality of Care (Apr to Jun 2024)

Staff Communication (Apr to Jun 2024)

Felt Safe in Hospital (Apr to Jun 2024)

Westside Private Hospital follows strict infection control procedures, and staff take every precaution to prevent infections. As patients are often discharged on 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 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 the period from April to June 2024, Westside Private Hospital provided care to 2686 patients. Through the diligent efforts of our doctors, staff, patients and visitors, we are proud to report zero post-surgical infections and an 86.5% hand hygiene compliance rate during this time.

Post-Surgical Infections (Apr to Jun 2024)

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 April to June 2024, we cared for 2686 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 none of our patients sustained an injury from April to June 2024.

Patient Falls
(Apr to Jun 2024)

Pressure Injuries
(Apr to Jun 2024)

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 follow strict guidelines so 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.

We can confirm there was one medication error at our hospital for the last reporting period. Our hospital will continue to review and improve the current strategies we have in place for medication safety.

Medication Safety
(Apr to Jun 2024)

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 April to June 2024, we cared 2686 patients, none of whom needed to return to theatre after surgery.

Unexpected Returns to Theatre
(Apr to Jun 2024)