Accreditation, Quality & Safety
Measures of Hospital Performance
At Mount Hospital, we take quality and safety seriously. To help patients make informed decisions, Mount 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 Mount 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
Rehabilitation Health Outcomes
Infection Rates
Patient Falls
Unplanned Readmission to Hospital
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.
Mount 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
Mount 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 Mount Hospital at their accreditation survey (Organisation Wide) in August 2009 is similar to other Australian hospitals.
Mount Hospital received a full four-year accreditation status in August 2009, gaining Extensive Achievement (EA) ratings in the following areas:
- Infection Control
- Health service information to patients and the community
- Human resources planning
- Learning and development of staff
- Credentialing of doctors and other health professionals
Quality improvement projects currently underway at Mount Hospital include:
- Implementation of the new National Safety and Quality Health Service Standards
- Refurbishment of our operating suite complex
- Redevelopment and expansion of our Central Sterilising Services Department
- Expansion of our Rehabilitation Unit
- Development of our allied health services
- Further development of our falls management program
- Expansion of our clinical audit program to monitor patient safety
- Development of community feedback forums
- Review of our clinical handover practices
- Improvement in our pressure ulcer prevention practices
Other Awards
In addition to accreditation, Mount Hospital is proud of the recognitions of excellence bestowed on its hospitals and staff.
Examples of recent awards are:
2010 Healthscope Service Excellence Awards
Melissa Sandford
Clinical Nurse (Theatre)
Mount Hospital (WA)
Melissa actively promotes occupational health and safety and has instituted a number of recycling projects to promote a more environmentally friendly workplace.
2008 Enrolled Nurse of the Year (WA)
Jacqueline McDonald
Mount Private Hospital (WA)
Jacqueline was a finalist for her design of a hand splint used in shoulder arthroscopies in Australia and overseas. It’s known as the "McDonald Splint".
Rehabilitation Health Outcomes
Patient abilities, mobility and independence are measured on admission to Mount Hospital and again on discharge so that we can measure the improvement made. Patients demonstrate improvement in their abilities, mobility and independence after treatment at Mount Hospital. We use the FIM™ (Functional Independence Measure) to measure the success of rehabilitation. This is an established scale, used worldwide.
Improvement in patient abilities will depend on factors such as patient age, severity of condition on admission and other medical problems such as diabetes or dementia. The graphs below show some of these factors.
This chart shows that patients at Mount Hospital are of a similar age on average to patients in other Australian private hospitals.
This chart shows that fewer patients at Mount Hospital have severe impairments on admission than patients in other Australian private hospitals.
See a definition for severity
Orthopaedic Fracture Rehabilitation
This graph shows the average improvement in patients at Mount Hospital following rehabilitation after a broken bone. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Rehabilitation patients at Mount Hospital achieve good outcomes compared with those of patients in other Australian private hospitals.
Rehabilitation for Hip, Knee or Shoulder Replacement
This graph shows the average improvement in patients at Mount Hospital following rehabilitation after a hip, knee or shoulder replacement. The dark coloured bar shows patient abilities on admission and the pale bar shows that these abilities have increased on discharge. Rehabilitation patients at Mount Hospital achieve good outcomes compared with those of patients in other Australian private hospitals.
What we are doing to continually improve our patients’ rehabilitation
- Individual and group therapy – individualised therapy time which may include practising tasks of daily living
- Multi-disciplinary team assesses and works with patient to set and meet goals
- Use of Functional Electrical Stimulation (FES) to improve strength and function in stroke patients
- Depression screening for all stroke patients (if depressed not able to participate fully in rehabilitation)
- Swallowing and speech/language therapy by Speech Pathologists
Infection Rates
Mount 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 Mount 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 Mount 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 infection caused when this bacteria enters the blood stream.
This graph shows the number of Staphylococcus aureus infections at Mount 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 Mount Hospital on average have a very low number of infections.
This graph shows the number of Clostridium difficile infections at Mount 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 Mount Hospital on average have no Clostridium difficile 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 Mount 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 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 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 Mount 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 Mount 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 Mount Hospital with other hospitals of a different size. Patients at Mount Hospital on average have a lower rate of falls than those in other hospitals.
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 Mount 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
Unplanned Readmission to Hospital
After a successful hospital stay, the most important task for patients, families and staff is preparing for a successful discharge home. It is disappointing for everyone if a patient requires an unexpected readmission into hospital.
Tracking the number of patients who experience unplanned readmissions to The Mount Hospital after a previous hospital stay is one way that we can judge the quality of hospital care. One example of an unplanned readmission would be someone who is readmitted to the hospital for a surgical wound infection that occurred after his or her initial hospital stay.
It is important to note that unplanned hospital readmissions may or may not be related to the previous visit, and some unplanned readmissions are not preventable. Good discharge plans can help reduce the rate of unplanned readmissions by giving patients the care instructions they need after a hospital stay and by helping patients recognise symptoms that may require immediate medical attention.
This graph shows the percentage of patients admitted to The Mount Hospital that have required an unexpected and unplanned readmission to hospital within 28 days of their first admission. The rate for the past 2 years is shown in the blue bars. This is compared to the rate of “unplanned readmission” in other Australian hospitals (the grey bar).
The graph shows that patients admitted to The Mount Hospital are less likely to have an unplanned readmission compared with other Australian hospitals.
There is a limitation to this data. Currently no unique patient identifier exists that would allow us to measure unplanned readmissions to a different hospital. Therefore the unplanned readmission rates presented in this graph represent patients readmitted to the same hospital only.
What we are doing to further reduce unplanned readmission rates
Improvement strategies may vary from hospital to hospital. Examples are:
- We review each case of readmission to check if there were any preventable factors.
- Check each patient’s risk for readmission
- Use a consistent process for discharging patients that includes making sure patients understand their medications and other instructions
- Arranging prompt follow up care and ongoing appointments, eg. with Physiotherapist and General Practitioner
- We monitor this data to make sure that the rate of unplanned readmission is not increasing.
Unplanned Return to Theatre
Mount Private Hospital has nine operating theatres 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 Mount 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 Mount 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
The Mount Private Hospital has investigated the increase in returns to theatre. There was an increase in the 2nd half of 2010 due to a more complicated type of surgery being performed during this period. The hospital is introducing new procedures to monitor recovery for these higher-risk patients, so that the rate of return to theatre should reduce in the next measurement period.
Other improvement strategies include:
- 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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