Patient Safety & Quality
Pindara Day Procedure Centre is committed to ongoing improvement or patient care in all areas. While we have an excellent record in delivering quality patient care and managing risks, our hospital continues to focus on improvements to ensure that our services are as safe as possible and that we are minimising risks at all times.
Pindara Day Procedure Centre has a strong commitment to safety and quality and this is reflected in our approach to:
- Creating safe environments and systems of work for our staff;
- Reviewing and improving on a continuous basis the performance of our patient safety and quality systems;
- Assisting our healthcare professionals and visiting Medical Practitioners to monitor the safety and quality of care they provide;
- Ensuring accountability for the safety and quality of care at all levels of our organisation reporting through to the Board of Ramsay Health Care.
Pindara Day Procedure Centre operates under Ramsay Health Cares’ comprehensive Clinical Governance Framework based on integrated approach to clinical risk management and continuous quality improvement. This Framework measures four major areas of organisational performance including:
- Clinical Risk Management (making sure our services are safe and minimising risk of error)
- Our culture promotes and encourages staff to report incidents, risks and near misses;
- Incident Management policy outlines the process for assessing and investigating incidents;
- Clinical policies are developed in accordance with evidence based best practice;
- Clinical, risk and safety policies are reviewed on a regular basis and updated as required; and
- Strategy and policy for ‘whistle blowers’.
- Clinical Effectiveness (making sure that the clinical services we provide are effective)
- Quality and Safety Indicators are used to measure and monitor performance
- Quality plans are initiated when significant issues are flagged;
- Quality and safety Indicators are benchmarked nationally;
- Serious clinical incidents are reported and investigated;
- Clinicians are represented on the national Governance Committee and National Working Parties;
- High risk areas are audited on a regular basis;
- Quality performance and safety issues are reported to the Ramsay Board; andAll facilities meet the standards for accreditation by National Quality and Health Care Standards.
- Effective Workforce (making sure our staff are competent and up-to-date)
- Facility Rules are available to all existing and new medical and allied health personnel;
- Ensuring a strict process for checking credentials, registration and scope of practice for all clinical disciplines;
- Targeted education and competency requirements in all clinical areas with a particular focus on high risk areas; and
- Staff are orientated and updated on quality and risk systems.
- Consumer Participation (involving our patients and carers in their care)
- Consumers participated in our risk management and quality improvement activities;
- Consumer complaints and feedback processes are managed in a timely way;
- Consumer feedback form patient satisfaction surveys informs strategic and business planning
- Consumer participate and partner in improving patient experiences and health outcomes;
- Health and safety performance is publicly available on hospital websites; and
- Open disclosure between clinicians and consumers is actively promoted when things don’t go to plan.
Our safety & Quality Performance
NA = Not available at this time
NR = KPI is not relevant to this facility
All Australian facilities are accredited using the National Quality & Health Standards which was introduced in 2013.
Accreditation is an important driver for safety and quality improvement. Through accreditation, Pindara Day Procedure Centre has been able to assess our level of performance in relation to established national and international standards and to implement ways to continuously improve our service delivery.
(Staph Aureus bacteraemia)
At Pindara Day Procedure Centre we aim to minimise the risk of infection to patients, staff and visitors who come to our facility.
One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands.
Hand hygiene is conducted in accordance with the ‘five moments’ that is; before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment.
Pindara Day Procedure Centre participates in the national hand hygiene strategy through Handy Hygiene Australia. Hand hygiene audits are conducted three times per year.
Visitors to this hospital are encouraged through appropriate signage to use antiseptic hand rub located throughout the hospital.
The Hand Hygiene brochure has more information on hand hygiene.
The risk of falling increases according to age with data suggesting that one third of people over the age of 65 have one or more falls a year.
Falls-related injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries may result in hospitalisation or an increased length of stay in hospital. The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medications and walking in unsafe footwear or slippers.
Our falls prevention program targets those patients who we identify as being at risk. We use specific criteria and tools to risk assess our patients and then put in place a number of strategies to minimise falls whilst in hospital. We do this by educating our staff to ensure that the patient’s call button and personal items are in reach; that call bells are attended to promptly; that patients are assisted to the toilet at regular intervals; and that patients have the appropriate walking aids.
Our Falls Prevention brochure entitled “Keeping on your Feet” has more information on preventing falls.
Unplanned Return to Theatre
We monitor any unplanned return to the operating room within the same hospital admission and review the data collected to identify any action required. Obviously, a low rate of return to theatre is desired, however, sometimes a return to theatre is unavoidable and can be a life-saving measure.
Unplanned Readmission to Hospital within 28 Days
Our hospital reviews patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge planning processes.
Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors. Pindara Day Procedure Centre is continually reviewing and implementing a range of medication safety strategies to further improve performance in this area.
The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and Pindara Day Procedure Centre has adopted many of these strategies. This includes the National Inpatient Medication Chart which standardises the documentation on how medicines are prescribed and ordered. Adoption by Pindara Day Procedure Centre of the User-Applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered.
In addition, Pindara Day Procedure Centre has medications administration policies and processes in place which have been developed using best practice principles.
Pindara Day Procedure Centre takes all medication errors very seriously. We encourage staff to report all errors no matter how minor they may seem. All medication incidents are investigated and actioned and any serious medication incidents are investigated thoroughly and monitored by the national Clinical Governance Unit.
Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.
Pindara Day Procedure Centre is well equipped with the latest equipment to assist staff to prevent these injuries from occurring. Patients are risk-assessed on admission using an evidence-based tool. Staff follow a care plan which is targeted to minimising a patient’s risk of developing a pressure injury for those patients assessed as high risk. This includes inspecting the patients skin frequently, managing moisture, keeping the skin dry, optimising nutrition and hydration and moving the patient frequently or using special pressure relieving mattresses when needed.
Our Pressure Injury Prevention brochure has more information on preventing pressure injuries.
Pindara Day Procedure Centre focuses on listening and responding to the needs of our patients. Your feedback allows us to continually evaluate feedback from our patients via our website, or via our patient satisfaction surveys. It is advisable that you express your concerns before you leave the hospital so we can fix any problems for you.Alternatively, there are a number of other ways that you can voice a concern. Our website contains a link to the Australian Charter of Healthcare Rights and this suggests a number of ways for you to express your concerns.
Smoke Free Campus
Pindara Day Procedure Centre is a smoke free campus. Please be aware that from 1 January, 2015 it is against the law to smoke at all public and private health facilities and five metres beyond their boundaries. Private health facilities include hospitals and day hospitals. The new laws, introduced by the Queensland Government, apply to the use of all smoking products, including regular cigarettes and devices commonly known as electronic cigarettes (e-cigarettes). Smoking is only permitted beyond the five metre buffer around the perimeter of hospital and healthcare facility boundaries. The laws are enforced by Queensland Health Environmental Health Officers and public facility authorised officers.
Patients and Carers
Patients and carers play an important role in the safe delivery of health care. Health care can be improved when the hospital service provider, patients and carers, and the medical and clinical teams work together to ensure the patient receives the most appropriate care and highest quality service possible.
To achieve this, patients and carers are encouraged to be proactive participants in the management of health care and health treatment plans during and after a stay in hospital.
Pindara Day Procedure Centre invites and encourages patients and carers to:
- Accept responsibility for the role they play in the delivery of care;
- Partner with Pindara Day Procedure Centre in the delivery of care, during and after a hospital stay;
- Communicate and share experiences that may impact on the relevant treatment plan during and after a hospital stay;
- Participate in making decisions that may impact on the relevant treatment plan during and after a hospital stay;
Pindara Day Procedure Centre encourages patients and carers to understand their own health care rights and responsibilities.
Escalation of Care
Patients and their families / carers play an important role in providing information to the health care team. If at any stage during your hospital admission you or your family / Carer identify deterioration in your condition or have any concerns about your care, you are encouraged to call for assistance immediately.
You can do this by:
- Pressing the nurse care button near your bed or chair
- Asking to speak to the Nurse in charge
- Asking to speak to your Doctor
Visitor Code of Conduct
Pindara Day Procedure Centre has a Code of Conduct for visitors. Visitors should be aware that a certain level of behaviour is expected of them when they are in the hospital. Visitors should also be mindful that hospital staff have rights in ensuring the protection of patients, staff and other visitors. All visitors to Pindara Day Procedure Centre have the following obligations to other visitors, patients, doctors and hospital staff:
- Keep noise to a minimum so as not to disturb others
- To comply with lawful requests by Medical Practitioners and Pindara Day Procedure Centre staff
- Not to smoke within the hospital
- Not to consume alcohol
- Respect the property of others and not to damage or misuse the property
- Be courteous and polite
- Show consideration and respect for the dignity and privacy of other patients
- Comply with visiting times
- Should a hospital staff member believe a visitor’s behaviour is improper, staff may:
- Request visitors to behave in accordance with this Code of Conduct
- Request visitors to leave the hospital
- Take all reasonable and necessary action to escort offenders from the hospital premises and to ensure that they do not return to the hospital
- Pindara Day Procedure Centre reserves the right to take any action which may be necessary to prevent any disruption by any person upon the hospital premises and by entering the premises all visitors accept this Code of Conduct.