Patient Safety and Quality

and Quality

Patient safety aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events. Patient safety is fundamental to delivering quality essential health services. A safe and high-quality health system provides the most appropriate and best-value care, while keeping patients safe from preventable harm.

MSPH is committed to the continuous improvement of our operations, maintaining a strong consumer focus and providing a consistent framework of sound corporate and clinical governance.

NSQHS Standards

National Safety
and Quality

Health Service
(NSQHS) Standards

The NSQHS Standards were developed by the Commission in collaboration with the Australian Government, states and territories, private sector providers, clinical experts, patients and carers.

The primary aims of the NSQHS Standards are to protect the public from harm and to improve the quality of health service provision.

The eight NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health services. To find out more about the National Standards, please click on the icons below.

NSQHS Standards
Quality and Continuous Improvement Program

& Continuous


MSPH is committed to the continuous improvement and monitoring of our operations, maintaining a strong consumer focus whereby patient centred care is at the forefront and ensuring that Quality & Continuous Improvement is intrinsic throughout the organisation.

The Quality & Continuous Improvement Program is based around the following fundamental activities:

        • Development, implementation and evaluation of a Quality Plan and Register
        • Development and review of policies and procedures that guide the corporate and clinical governance of the hospital and ensure compliance with relevant legal and regulatory obligations
        • Collection, auditing, monitoring and analysis of data meeting KPI indicators and objectives
        • Implementation of a comprehensive clinical indicator program
        • Review of outcomes and evaluations, and implementation of recommendations from system reviews
        • Establishment of reporting mechanisms to provide follow up and feedback to appropriate and relevant personnel/committees
        • Establishment of mechanisms to ensure that patient needs, feedback and satisfaction are identified and understood, with the objective of partnering with consumers and achieving patient centred care in order to meet, and where possible exceed, patient expectations.
        • Robust system is in place to manage complaints, incidents and risks and ensure that they link into the quality system as appropriate
        • Maintenance of NSQHS certification and compliance as applicable with the Australian Commission on Safety and Quality in Health Care National Standards


and Control

MSPH infection prevention systems are designed to minimise the risk of health care-associated infections. MSPH conduct an Infection Control System Audit to assist management to develop and implement systems to eliminate or minimise potential risks to patients, workers and visitors.

Infection Control System Audit
Monash Surgical Private Hospital

Quality and Continuous Improvement Program
NSQHS Standards


Medication errors include any errors in dispensing, prescribing or administering medication. Errors in medication administration are captured in the hospital’s incident reporting system and investigated. MSPH conduct regular audits covering all aspects of safe medication management.

The graph below shows MSPH has recorded zero medication errors.

Medication Errors Audit
Monash Surgical Private Hospital

NSQHS Standards
Quality and Continuous Improvement Program


It is important to check that healthcare workers are using correct hand hygiene. Hand hygiene auditing is used at MSPH to monitor compliance against the critical times when hand hygiene should be performed in hospital. These are:

  • Before touching a patient
  • Before a procedure
  • After a procedure
  • After touching a patient
  • After touching a patient’s belongings or surroundings

Hand Hygiene Staff Compliance
Monash Surgical Private Hospital 2020

When audits are performed, each professional group is checked including doctors, nurses and other hospital staff. The graph below shows which groups were audited and the hand hygiene compliance rate for different staff within the hospital.

Hand Hygiene Staff Compliance
Monash Surgical Private Hospital 2020

Fire and Emergency
Skills Competency

Monash Surgical Private Hospital conducted the QPS Benchmarking Staff Competency Fire and Emergency Skills during April 2022. The competency tests were conducted online, where employees were provided with a web based link to the QPS competency test to directly capture their results.

Table 1. Response Rate
Monash Surgical Private Hospital

Table 2. Industry Benchmark Competency Result
Monash Surgical Private Hospital


The graph below demonstrates the Employee Survey results and the current QPS Benchmark Result for each survey domain.

Employee Satisfaction Survey – Domain Results Total % Score
Monash Surgical Private Hospital

Quality and Continuous Improvement Program
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