Patient Safety and Quality

Safety
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

Quality
& Continuous
Improvement

Program

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

Infection
Prevention

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

Date: 1/07/2023
Audit Result: 100.00%

Domain Result
1.1 Clinical Governance 100.00%
1.2 Managing Infection Risks 100.00%
1.3 Training Requirements 100.00%
1.4 Quality Improvement System 100.00%
1.5 Partnering with Consumers 100.00%
1.6 Surveillance and Structure 100.00%
2.1 Standard and Transmission-Based Precautions NA
2.2 Hand Hygiene 100.00%
2.3 Aseptic Technique 100.00%
2.4 Clean and Safe Environment 100.00%
2.5 Workforce Screening and Immunisation 100.00%
3.0 Reprocessing of Reusable Medical Devices 100.00%
4.0 Antimicrobial Stewardship 100.00%
Quality and Continuous Improvement Program
Quality and Continuous Improvement Program

Hand
Hygiene

The ‘5 moments of hand hygiene’ are employed at MSPH in accordance with Hand Hygiene Australia i.e. before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment. It is mandatory that all MSPH Staff complete the online Hand Hygiene learning module. Mandatory competencies are also available for all clinical staff to complete with completion of these competencies monitored by our Quality Management Systems.

Hand Hygiene Compliance

NHHI Audit Two 1st April 2023 – 30th June 2023

Hand Hygiene Compliance

NHHI Audit Three 1st July 2023 – 31st October 2023

Clinican
Satisfaction

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

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

Patient
Experience

The graph below demonstrates the Patient Survey results and the QPS Industry Benchmark for each survey domain.

Patient Experience Survey – Domain Results Total % Score
Monash Surgical Private Hospital

April 2023 – June 2023

Overall Results – 96.42%

Patient Experience Survey – Domain Results Total % Score
Monash Surgical Private Hospital

July 2023 – September 2023

Overall Results – 94.15%

Patient Experience Survey – Domain Results Total % Score
Monash Surgical Private Hospital

October 2023 – December 2023

Overall Results – 94.43%

Employee
Satisfaction

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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