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.
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.
Quality
& Continuous
Improvement
Program
Monash Surgical Private Hospital (MSPH) is dedicated to integrating quality management and improvement into its operations to foster a culture of continuous monitoring and enhancement of service and care quality. The primary goals are patient and staff safety, as well as achieving patient-centred care.
The Quality & Continuous Improvement Program is centred around the following fundamental activities:
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- 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, ensuring compliance with relevant legal and regulatory obligations
- Collection, auditing, monitoring, measurement and analysis of relevant data meeting KPI indicators and objectives
- Implementation of a comprehensive clinical indicator program
- Review of outcomes and evaluations, with implementation of recommendations from system reviews
- Establishment of reporting mechanisms to provide follow-up and feedback to appropriate personnel and committees
- Establishment of mechanisms to ensure that patient requirements, feedback and satisfaction are identified and understood, with the objective of partnering with patients to achieve patient-centred care and meet, and where possible, exceed patient expectations
- Implementing a robust system to manage complaints, incidents, and risks, ensuring these are integrated into the quality system as appropriate
- Conducting continual reviews of mechanisms and processes involved in quality activities and implementing improvements, undertaking preventative and corrective actions as required
- Maintenance of NSQHS certification and compliance with the Australian Commission on Safety and Quality in Health Care National Standards
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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.
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 Three: 1 July 2025 – 31 October 2025
Clinician
Satisfaction
Monash Surgical Private Hospital conducts an annual clinician satisfaction survey through independent QPS Benchmarking. Results from October 2025 demonstrate high levels of clinician satisfaction across clinical care, hospital services, and governance, with performance above national industry benchmarks. This feedback supports continuous improvement in the delivery of safe, high-quality patient care.
Clinician Satisfaction (October 2025): Independent QPS Benchmarking results indicate strong clinician satisfaction across governance, clinical practice, and service delivery domains, with performance above national industry benchmarks.
Clinician Satisfaction Survey – Domain Results Total % Score
Monash Surgical Private Hospital
October 2025 Overall Results 97.91%
Patient
Experience
Monash Surgical Private Hospital collects patient feedback through independent QPS Benchmarking surveys to better understand the patient experience of care. Results show high levels of satisfaction with communication, care delivery, and overall hospital experience. This feedback is reviewed by hospital leadership and used to guide ongoing improvements in patient care and service delivery.
The graph below demonstrates the Patient Survey results and the QPS Industry Benchmark for each survey domain.
October 2025 – December 2025
Overall Results – 95.79%
Staff
Safety Culture
Monash Surgical Private Hospital conducts staff safety culture surveys twice each year to understand how safe and supported our staff feel at work and how effectively our safety systems are operating.
Results from our October 2025 survey show strong staff confidence in leadership, training, and patient safety reporting practices. This feedback helps guide ongoing improvements in patient safety and workplace culture.
Staff Safety Culture Survey Results – October 2025
