Accreditation, Quality & Safety
Measures of Hospital Performance
At John Fawkner Private Hospital, we take quality and safety seriously. To help patients make informed decisions, John Fawkner Private Hospital publishes a number of safety and quality indicators. This is just one part of our program to continually maintain and improve our high standards of quality and safety.
Quality can be defined and measured in many ways. At John Fawkner Private Hospital, quality is not just a simple measure – it is a comprehensive look at many aspects of a patient's experience. We have chosen to publish a range of clinical and safety measures which provide you with information about our performance in providing safe, quality healthcare. Click on the links below to view our data.
Accreditation
Infection Rates
Patient Falls
Emergency Department Waiting Times
Unplanned Return to Theatre
Many organisations today are measuring quality in health care using varying criteria. Evaluating this information can be difficult and time-consuming since not all measures reflect the same information from one report to another. However, it is important for patients to ask questions and look at quality information to ensure they are getting the efficient and effective care they need.
John Fawkner Private Hospital supports transparent public reporting of healthcare quality data and actively participates in initiatives of the following organisations.
Australian Commission on Safety and Quality in Healthcare (ACSQHC) – The Australian Commission on Safety and Quality in Healthcare (the Commission) was established in 2006 by the Australian, State and Territory Governments to lead and coordinate national improvement in safety and quality. Healthscope has representation on the Private Hospital Sector Advisory Committee and several key working groups.
Australian Institute of Health and Welfare - The Australian Institute of Health and Welfare (AIHW) is a major national agency set up by the Australian Government under the Australian Institute of Health and Welfare Act to provide reliable, regular and relevant information and statistics on Australia's health and welfare.
MyHospitals Website – This website lists all public and private hospitals in Australia, along with information about waiting times for elective surgery and emergency department access. Healthscope has representation on the MyHospitals Development Advisory Committee.
Patient Stories
The experiences of our patients are another gauge of how well we are doing at caring for patients and their families.
To have a look at what they say, see: Patient Stories
Accreditation
John Fawkner Private Hospital is fully accredited by the Australian Council on Health Care Standards (ACHS) Evaluation and Quality Improvement (EQuIP) standards.
Accreditation involves a visit to the hospital from an independent team of expert health professionals who review the quality and safety of services provided. Our achievements are measured against best practice by this review team. Hospitals are measured against over 40 separate criteria including patient care planning, medication management, the consent process, medical records, infection control, complaints management and staffing. Hospitals receive a rating for each one of these criteria.
For hospitals accredited by ACHS, a higher level of award is sometimes given – this is referred to as “EA” or “extensive achievement”.
This chart shows that the proportion of “EA” ratings achieved by John Fawkner Private Hospital at their accreditation survey (Organisation Wide) in February 2011 is higher than other Australian hospitals.
Eight (8 ) EA ratings were awarded for Infection Control, Falls Prevention, Blood transfusions, meeting the needs of consumers with diverse backgrounds, Correct Patient, Incident and complaints management, Credentialing Processes and Safety Management Systems. Commendations were received for the continuous glucose monitoring program and medical emergency team.
Current Quality Improvement Projects include:
- Implementation of the Patient Centred Care Project inclusive of bedside handover, and hourly rounding.
Other Awards
In addition to accreditation, John Fawkner Private Hospital is proud of the
recognitions of excellence bestowed on its hospitals and staff. Examples of recent awards are:
2010 Healthscope Service Excellence Awards
The Falls Working Party
John Fawkner Private Hospital (VIC)
The Falls Working Party implemented improved risk assessment tool and changes to environmental factors, achieving a reduced number of falls. The risk assessment tool developed by the working party is now used in all Healthscope hospitals.
Infection Rates
John Fawkner Private Hospital has implemented numerous infection control procedures, and staff take every precaution to prevent infections. However, some patients have a higher risk of acquiring an infection in hospital. Patients with wounds, invasive devices (such as drips) and weakened immune systems are at greater risk of infection than the general public. We need to avoid infections because they may cause illness to the patient, resulting in a longer stay in hospital and a longer recovery time.
What are Healthcare Associated Infections?
Healthcare associated infections (HAI) are infections that occur as a result of healthcare interventions and are caused by micro-organisms such as bacteria and viruses. They can happen when you are being treated in hospital, at home, in a GP Clinic, a nursing home or any other healthcare facility.
Some infections occur after an invasive procedure such as surgery and can be treated with antibiotics. However there are some infections such as Methicillin Resistant Staphylococcus aureus (MRSA) and Clostridium difficile that are more difficult to treat because they are resistant to certain antibiotics.
The risk of getting these infections depends on how healthy you are, how long you have been in hospital and certain medications that you take (including antibiotics).
These specific infections require the use of special antibiotics and, at times, special precautions which may include placement in a single room and the use of personal protective equipment such as gloves and gowns.
What is John Fawkner Private Hospital doing to prevent infections?
Specialised Infection Control staff collect data on hospital acquired infections and analyse the data to identify patterns and trends. Infection rates are shared and discussed with clinicians in an effort to identify and implement the best practices to reduce the risks for infection.
There are several types of infections that we closely monitor at John Fawkner Private Hospital. Both are caused by bacteria. You may have heard of these:
- Clostridium difficile - this is an infection of the bowel that causes diarrhoea
- Staphylococcus aureus bacteraemia - known as “SAB” for short. This is a serious blood infection.
This graph shows the number of Staphylococcus aureus infections at John Fawkner Private Hospital for the year ending June 2011 compared with the Australian Government target. The graph shows the number of infections that occur for every 10,000 patient days. The national benchmark for Staphylococcus aureus bacteraemia in Australian public hospitals is no more than 2 cases per 10,000 patient days. Patients at John Fawkner Private Hospital on average have a very low number of infections.
This graph shows the number of Clostridium difficile infections at John Fawkner Private Hospital compared with the rate typical in other hospitals in Australia. Rates of infection typically vary from state to state. The rate varies from 2 to 3 cases per 10,000 days of patient care, so the industry rate reflects this range. The graph shows the number of infections that occur for every 10,000 patient days. Patients at John Fawkner Private Hospital on average have a very low number of infections.
To find out how we generated this data, see: Infection Rate Formulas
What we are doing to further reduce infections
Improvement strategies may vary from hospital to hospital. Examples are:
- Watching, auditing and measuring how often staff wash their hands using soap and water or hand sanitiser.
- Routine use of gloves and specially sterilised equipment.
- An Infection Control Nurse in each hospital, to investigate issues, educate staff and carry out strategies to reduce infections
- Use of specialised approved disinfectants for cleaning and disinfecting rooms, bathrooms, equipment and shared areas. High level disinfection and sterilisation are used according to national guidelines.
- Placement of hand sanitiser dispensers in public areas throughout our hospitals including hallways, elevators and cafeterias, making this readily accessible to staff, patients, families and visitors.
- If additional precautions are required, staff may wear gloves, gowns, masks and goggles.
How can you help?
At John Fawkner Private Hospital, patients and visitors are part of the health care team. Hand washing is the most important way that patients and visitors can prevent the spread of infection in hospital. Waterless hand sanitiser is just as effective as washing with soap and water. Hospital staff will appreciate a reminder from patients or relatives if they forget to wash their hands.
There are a number of things you can do to reduce the risk of infection:
- Wash your hands carefully with soap and water or use hand sanitiser upon entering and before leaving the hospital
- Cover your mouth and nose with a tissue when you cough or sneeze (or into your elbow if you don't have one). Clean your hands afterwards – every time!
- Report any infection you have had, especially if you are still on antibiotics
- Make sure you take the full course of antibiotics you have been given, even if you are feeling better
- If you have a dressing or a wound, keep the skin around the dressing clean and dry. Let the healthcare worker looking after you know promptly if it becomes loose or wet
- Tell the healthcare worker looking after you if the area around the drips, lines, tubes or drains inserted into your body becomes red swollen or painful.
- Let the healthcare worker looking after you know if your room or equipment hasn't been cleaned to you linking ( wording suggests that we don’t clen things properly)
- Stop smoking before any surgery, as smoking increases the risk of infection.
Visitors
- Reconsider your visit if you have an illness such as a cough, cold or gastroenteritis
- Wash your hands carefully with soap and water or use hand sanitiser when entering and leaving a patient’s room.
For more information about how you can help:
Read: Hand Hygiene Information Leaflet
Watch: Interactive Video Training
Link to: Better Health Channel
Patient Falls
Patients are often in a weakened or confused state in hospital, and are more susceptible to falling. Falls are a leading cause of hospital-acquired injury, and frequently prolong or complicate hospital stays. At John Fawkner Private Hospital we document and investigate every fall and take action to reduce the number of falls that occur.
This graph shows the number of falls in John Fawkner Private Hospital for the past 3 years, compared with the rate typical in other hospitals from Australia, the UK and the USA. Falls are presented as a percentage of patient days – allowing us to compare John Fawkner Private Hospital with other hospitals of a different size. Patients at John Fawkner Private Hospital on average have a lower rate of falls than those in other hospitals. The rate of falls has reduced in recent years, due to the actions taken by the Falls Working Party to improve risk assessment and introduce individual strategies for patients at risk.
See details on: How we work out our falls rate
For a discussion on the data, see: Limitations of data
What we are doing to further reduce falls
- Assessment of all patients for risk of falls
- Implementation of precautions to reduce the risk of falling for example:
Non-slip socks
Bed and chair sensors which detect patient moving from bed
Use of lifting equipment and walking aids
- Analysis of falls incidents
- Spot audits to provide information about environmental factors
How can you help?
At John Fawkner Private Hospital, you, as a patient or visitor are part of the health care team. Print a brochure containing handy hints about preventing falls in hospital and at home. You can also watch a helpful video.
Brochures
Video
Emergency Department Waiting Times
When a patient visits the Emergency Department at John Fawkner Private Hospital, the triage nurse carries out an assessment of how urgent the patient’s condition is. Each patient is assigned a triage category from 1 through to 5 on the Australasian Triage Scale. According to the best practice guidelines, patients must be seen for medical assessment and treatment within the following times:
- Category 1 patients must be attended to immediately (e.g., cardiac arrest);
- Category 2 patients attended to within 10 minutes (e.g., severe blood loss);
- Category 3 patients attended to within 30 minutes (e.g., head injury but conscious)
- Category 4 patients attended to within 60 minutes (e.g., sprained ankle, possible fracture)
- Category 5 patients attended to within 120 minutes (e.g., cut not requiring stitches)
Patients that are category 1, 2 or 3 will be seen before category 4 and 5, even if they arrive in the department at a later time. If you visit an Emergency Department you can ask the triage nurse what category you have been assigned and this may give you an idea of how long you may be expected to wait.
All hospitals with Emergency Departments measure how quickly patients are seen in the Emergency Department. The graphs below show the percentage of patients in each Category that are seen within the recommended time at John Fawkner Private Hospital. On average, patients visiting the Emergency Department at John Fawkner Private Hospital are seen more quickly than in other Australian hospitals.
What we are doing to improve our emergency response times
Improvement strategies may vary from hospital to hospital. Examples are:
- Continually reviewing our doctor and nurse staffing levels
- Monitoring the number of ambulance presentations to our Emergency Departments
- Monitoring bed availability for transfers to the ward Or other appropriate Healthscope facilities
Unplanned Return to Theatre
John Fawkner Private Hospital has an operating theatre and carries out many sessions of surgery every year. One of the ways of monitoring the success of surgery is to check whether any patients require an unexpected second operation – we call this “return to theatre ”. There are many reasons why a patient may need a further operation – however where possible we aim to minimise this number.
This graph shows the percentage of patients having an operation or procedure at John Fawkner Private Hospital that have required a return to theatre during the same admission. The rate for the past 2 years is shown in the blue bars. This is compared to the rate of “return to theatre” in other Australian hospitals (the grey bar).
The graph shows that patients undergoing surgery at John Fawkner Private Hospital are less likely to have an unexpected return to theatre compared with other Australian hospitals.
What we are doing to reduce unplanned returns to theatre
Improvement strategies may vary from hospital to hospital. Examples are:
- Careful monitoring of patients in recovery
- Ensuring patient’s level of pain is carefully assessed
- Reviewing every case when a patient requires a return to theatre, to work out the reasons why and how to prevent it in future
- Conducting thorough pre-operative evaluation including coagulation studies and anti-coagulant therapy management where indicated
- Preadmission assessment of high risk patients to make sure all required tests and precautions are taken
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