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: October to December 2022

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

Patient feedback provides valuable information and not only ensures that patients’ voices are heard, but by examining patients’ feedback it gives direct insight into our quality of care and patient satisfaction.  This aids in maintaining and improving the standard of care offered at Westside Private.  Patients are encouraged to provide feedback using the feedback form provided or by visiting our website.

Consumer satisfaction at Westside Private Hospital has been collated and graphed for analysis.  The last quarter shows a near perfect satisfaction rate with 99.9% of all surveyed patients providing positive feedback about their hospital experience and the level of care provided.

Consumer Satisfaction (Oct to Dec 2022)

Consumer Satisfaction 99.9%

Westside Private has a formal complaints process should a patient be dissatisfied with the level of specialist care or customer service at our hospital. During October to December 2022, we cared for 2573 patients and four complaints were received.

Consumer Experience
(Oct to Dec 2022)

At Westside Private Hospital we implement the highest standards in infection prevention and control including:

  •   Hand hygiene

  •   Use of Personal Protective equipment

  •   Safe use of disposal consumable equipment

  •   Reprocessing of medical equipment

  •   Routine Cleaning

Our systematic approach to preventing, controlling and responding to infections creates a safe environment for visitors and staff at our facility. Our latest quality report shows a very high 92% compliance rate in hand hygiene, and zero post-surgical infections during October to December 2022.

Westside Private Hospital
Post-Surgical Infections (Oct to Dec 2022)

Safety reporting systems are a very important aspect of ensuring patient safety at Westside Private. Detecting near misses and incidents enables us to improve practice and prevent any future adverse events. A near miss is an adverse event that has been intercepted and has not resulted in harm for example:

  •   Slip or falls not resulting in injury

  •   Medication error that has not resulted in harm (refer to Medication safety)

  •   Pressure Injuries resulting in no harm

At Westside Private we cared for 2573 patients during October to December 2022. We are pleased to report zero incidents of falls during this time and zero pressure injuries.

Incidents of Falls
(Oct to Dec 2022)

Pressure Injuries
(Oct to Dec 2022)

Medication errors can have an impact on patient outcomes and can cause harm. Westside Private Hospital’s medication safety systems are in place to prevent the occurrence of medical-related incidents. Staff are trained in the safe and appropriate use of medicines. 

Medication risks are described as errors in:

  •   Prescribing

  •   Administering and/or

  •   Dispensing medication

We are delighted to report a perfect score in Medication Safety when we provided care to 2573 patients from October to December 2022.

Medication Safety (Oct to Dec 2022)

Surgical complication requiring the unplanned return to theatre within one month of a patient’s most recent discharge from hospital is classified as an Unexpected Return to Theatre. The return subjects the patient to repeated anaesthesia risks, which can be highly distressing and impact the patient and their family. Returning to the theatre generally occurs because the patient experiences one of the following:

  •   Haemorrhage / bleeding

  •   Wound reopening

We are pleased to report there were no unexpected returns to theatre at Westside Private during October to December 2022.

Unexpected Returns to Theatre
(Oct to Dec 2022)