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John Fawkner Private Hospital

MyHealthscope - Accreditation, Quality and 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.

John Fawkner Private Hospital is fully accredited against The National Safety and Quality Health Service Standards, a mandatory set of standards established by the Australian Government for all public and private hospitals.

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 industry standards by this review team. Hospitals are measured against ten overarching standards and many different criteria including patient care, medication management, clinical handover, infection control, complaints management and preventing falls.

Hospitals receive a rating for each one of these criteria – either satisfactorily met or not met. If a criterion is not met, the hospital is given an action that it must follow-up within 3 months to ensure the criterion is satisfactorily met.

For hospitals achieving a higher level of quality, a higher rating is awarded “MM” or “met with merit".

This chart shows the proportion of “MM” ratings achieved by John Fawkner Private Hospital for their recent organisation wide survey compared to other Australian hospitals.

In April 2015 John Fawkner Private Hospital underwent a full accreditation survey against all 10 National Standards and is fully accredited by the Australian Council on Healthcare Standards (ACHS). A total of 41 Met with Merits were awarded.

The surveyors were impressed with the high degree of teamwork and the planned integration of services provided for patients, carers and clinicians and also identified the commitment that John Fawkner Private Hospital has to the process of increasing involvement of consumers so to ensure clinical care is of high quality with a strong focus on evidence-based, patient centred care.

Listed are the following achievements and ongoing quality improvement activities we have implemented and practice to support and achieve all 10 National Standard Guidelines.


Patient Centred Care Project

This is a project that was implemented over 3 years ago to improve care and communication with our consumers. It includes bedside handover and hourly rounding to engage and educate patients and carers in reducing the risk of falls, malnutrition, venous thromboembolism and pressure injuries, including access to a wound care specialist nurse who provides resources to patients and staff on the prevention of pressure injuries in hospital. We also have a Blood Transfusion Clinical Nurse on site who has developed education packages for both patients and staff about blood transfusions and informed consent.

From introducing the Patient Centred Care Program there has been a 4.7% increase in Patient satisfaction scores over a 12 month period (2013-2014).

To ensure our patients and carers are well informed, Consumer Information brochures have been developed and are available pre-admission or upon admission, and many are available in multilingual format. Some of these Include:

  • Keeping a Step Ahead of Falls
  • Move, Move, Move - Preventing Pressure Injuries
  • Stop the Clot, Reducing Your Risk of Blood Clots
  • Blood Transfusions, Frequently Asked Questions


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:

2015 Healthscope Achievement Award - Best Accreditation Performance
John Fawkner Private Hospital
2015 Healthscope Service Excellence Award - Quality Improvement -runners up

Transfusion Clinical Nurse Consultants
John Fawkner Private Hospital
Our Transfusion Clinical Nurse Consultant won the award for compliance with the HSQHS Standard 7 - Blood and Blood Products resulting in positive outcomes for patients, doctors and staff and making a significant difference to safe and efficient blood practices across the hospital. The achievement was also recognised by receiving an award from the National Blood Authority’s 2015 Excellence in Blood Management

2015 Healthscope Service Excellence Award - Aspiration - runners up

Quality and Consumer Consultants

John Fawkner Private Hospital
The team championed a best practice model for consumer consultation and participation. The outstanding result is a robust and structured program that has significantly increased patient satisfaction rates and experience and improved quality and patient safety outcomes.

2013 Healthscope Achievement Award - Best Accreditation Performance

  • John Fawkner Private Hospital
  • 2013 Healthscope Service Excellence Awards - Quality Improvement
  • 2nd Floor Surgical Unit/ICU
  • John Fawkner Private Hospital (VIC)

Won the award for Quality Improvement for their world-first study, comparing the sensitivity of two renonwned Early Warning Track and Trigger systems. An abstract from the findindgs of the reseach has been submitted for consideration for the 8th International Rapid Response Conference - Royal College of Physicians, London.

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.

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 2015 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

Hand Hygiene is another name for hand washing or cleaning. Hands can be effectively cleaned with either soap and water, or with waterless hand sanitiser. Both are equally effective. It is an expectation that all staff at John Fawkner Private Hospital frequently clean their hands.

Hand hygiene is simple and is the most important way of preventing infections in hospital. Our hands may look clean but many germs are invisible to our eyes. We can unknowingly transmit bacteria and viruses to others and our environment. Germs can survive on unwashed hands for over an hour.

People (especially children) sometimes take short-cuts when they are supposed to wash their hands – particularly when there is no dirt visible. And unfortunately, hand hygiene is sometimes not well performed by health care workers.


What is John Fawkner Private Hospital doing to improve hand hygiene?

It is important that we check whether healthcare workers are using correct hand hygiene. There is no magic way of knowing if a person has washed their hands. The accepted way of measuring hand hygiene is for a trained auditor to watch healthcare workers as they go about their day, treating patients in hospital. There is a government-approved organisation called ‘Hand Hygiene Australia’ that helps with this measurement. John Fawkner Private Hospital has a “gold-standard auditor" on site, accredited through Hand Hygiene Australia. This person is trained to check that staff are washing their hands as often as they should.

Each opportunity for hand hygiene is called a “moment”. Five Moments for hand hygiene have been identified by the World Health Organisation as the critical times when hand hygiene should be performed in hospital. These are:

  • Before touching a patient
  • Before a procedure
  • After a procedure
  • After touching a patient
  • After touching a patient’s belongings or surroundings

At John Fawkner Private Hospital we watch staff during each of these moments. The auditor records whether or not hand hygiene has been performed correctly by each staff member at each “moment”. At the end of the audit, an overall score is calculated. This is shown in the graph below.

This graph shows the percentage of moments where hand hygiene was performed correctly at John Fawkner Private Hospital for the past 4 years compared with the Australian national benchmark of 80%.

Staff at John Fawkner Private Hospital on average have a high rate of compliance with hand hygiene. This suggests that our hand hygiene program is working.

The more hand hygiene moments are audited, the more reliable our figures . This figure shows how many hand hygiene moments were audited at John Fawkner Private Hospital in the most recent period audited. Note that smaller hospitals are required to audit fewer ‘moments’ than larger hospitals.

When audits are performed, each professional group is checked – including doctors, nurses, cleaning and other hospital staff.

The graph on the left (below) shows which groups were audited. The graph on the right (below) shows the hand hygiene rate for different staff within the hospital. The graph shows that compliance rates for all staff at John Fawkner Private Hospital are very high.

The graph below shows that doctor hand hygiene rates have improved since we introduced public reporting on this website in 2013.


What we are doing to further reduce infections

The reasons for staff not performing hand hygiene may include:

  • Time pressure - there just is not enough time to wash hands as often as necessary.
  • Hands do not appear dirty – but germs are there, even if they cannot be seen.
  • Problems with skin irritation - frequent washing with soap and water can cause dryness, skin irritation or damaged skin which makes washing uncomfortable.

Improvement strategies may vary from hospital to hospital. At John Fawkner Private Hospital the following strategies are used:

  • Conducting regular education programs for staff about infections and hand hygiene.
  • An Infection Control Nurse to investigate issues, educate staff and carry out strategies to reduce infections.
  • Placement of hand sanitiser dispensers in convenient areas throughout the hospital, including hallways and patient rooms. This makes hand hygiene readily accessible to staff, patients, families and visitors.
  • Monitoring the type of soap/hand sanitiser used, to minimise skin irritation
  • In some areas - use of specially designed washbasins where water can be turned on and off without touching the tap.


How can you help?

At John Fawkner Private Hospital, patients and visitors are part of the health care team. Hand hygiene 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 leaving the hospital.
  • Wash your hands carefully with soap and water or use hand sanitiser when entering and leaving a patient’s room.
  • Observe hospital signage about hand hygiene.
  • If you are unable to find a hand sanitiser station, please ask staff for assistance.


For more information about how you can help:

Read: Hand Hygiene Information Leaflet
Watch: Interactive Video Training
Link to: Better Health Channel

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 5 years, compared with the industry rate. 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.

A pressure injury is an area of skin damage, such as a wound, sore or ulcer, or an area of persistent reddening, caused by direct pressure on the skin. This can sometimes occur when a patient is in one position and unable to move easily for a long period, although not every patient is at risk. Pressure injuries can range in severity from an area of reddened but intact skin to broken skin, which may involve varying degrees of underlying tissue damage.

Pressure injuries frequently prolong or complicate hospital stays. At John Fawkner Private Hospital we document and investigate every case and take action to reduce the number of pressure injuries that occur.

When patients are admitted to hospital, an assessment is performed of the skin to determine if any pressure injuries already exist and also to decide whether the patient is at risk of developing a pressure injury. Patients that may be at risk are those that are:

  • Bedbound
  • Have sensitive skin
  • Poor nutrition
  • Older
  • Taking certain medications, or
  • Have chronic illnesses such as diabetes or anaemia.

John Fawkner Private Hospital has many strategies in place to prevent pressure injuries developing. If a pressure injury develops, the hospital staff do everything they can to help it heal as soon as possible.

One of the ways of monitoring the success of our prevention strategies is to check whether any patients have developed pressure injuries in hospital.

This graph shows the number patients at John Fawkner Private Hospital that have developed a pressure injury during their admission to hospital. The rate for the past 4 years is shown in the pink bars. This is compared to the rate of pressure injuries in other Australian hospitals (the grey bar). The graph shows that patients at John Fawkner Private Hospital are less likely to develop a pressure injury compared with other Australian hospitals.

Although the overall number of pressure injuries has risen, it is important to identify pressure injuries at an early stage. Identifying more stage 1 pressure injuries (with redness and unbroken skin) can often be a good thing, as it allows hospitals to put strategies in place to prevent the injuries from getting any worse.

Sometimes, despite our best efforts, a patient does develop a pressure injury - however we aim to minimise this number.

What we are doing to reduce pressure injuries

Improvement strategies may vary, examples are:

  • A risk assessment is performed to identify patient that are vulnerable to pressure injuries
  • Patients identified as ‘high risk’ are referred to the dietitian for nutritional assessment and advice
  • Pressure relieving devices are used. These include specialised mattresses, cushions, wedges, sheepskins, water-filled supports, contoured or textured foam supports, heel elevators, gel-filled supports and bead filled supports.
  • Preventing exposure to excessive moisture or dryness
  • Positioning: Regularly changing the position of the patient and encouraging walking or movement if possible
  • Individual reporting: Examining each case of pressure injuries to determine why it occurred and how to prevent this happening again
  • Education for nursing staff in pressure injury identification, prevention and management
  • Patient education provided on pressure injury prevention at pre admission and or admission
  • Referral to a wound management consultant in the event of a pressure injury developing or if admitted with a pressure injury.

A blood transfusion is a procedure where you receive blood through an intravenous cannula (IV) inserted into a vein. You may need a blood transfusion if your body cannot make parts of your own blood, if your blood cells are not working properly, or if you have lost blood.

Blood contains red cells which are essential for carrying oxygen around the body. A blood transfusion may be given because of a shortage of red blood cells in the blood (anaemia), either because the body is not making enough of them, or because of blood loss. Sometimes the bone marrow, which produces blood cells, doesn’t work properly. The bone marrow can be affected by chemotherapy or diseases. In some cases anaemia can be treated with medicines but in other cases, a blood transfusion may be the best treatment.

Most people can cope with losing a moderate amount of blood without needing a blood transfusion, as this loss can be replaced with other fluids. However, if larger amounts of blood are lost, a blood transfusion could be the best way of replacing blood rapidly. A blood transfusion may be needed to treat severe bleeding, for example during or after an operation, childbirth or after a serious accident. There are are many useful resources for patients about blood transfusion available.

Transfusion does not just refer to blood – often other blood products are used. These include:

  • fresh blood components, such as red blood cells, platelets, fresh frozen plasma or cryoprecipitate
  • plasma-derivatives such as albumin, immunoglobulins and clotting factors.

A blood transfusion can be lifesaving or significantly improve quality of life. Australia has one of the safest blood supplies in the world, however, as with all medical procedures, a blood transfusion is not completely free from risk. It is very important that all patients receive blood and blood product transfusions appropriately and safely. Blood transfusions are given to patients only where the doctor has assessed it as absolutely necessary.

Patients must give consent for a blood transfusion. Consent should be documented on a consent form or by documenting the discussed information in your medical record.

It is very important that transfusions are carried out by trained professional staff, using the techniques outlined in the National Safety and Quality Health Service Standards. This is double checked and audited on a regular basis in our hospital.

One way that we monitor the success of blood transfusions is by keeping track of any adverse reactions – both major and minor. Adverse reactions are rare, but can include:

  • incorrect blood / blood component transfused
  • transmission of infection, for example bacteria or viruses
  • transfusion related immune reaction
  • transfusion related acute lung injury.

At John Fawkner Private Hospital we document and investigate every case and take action to reduce the number of adverse transfusion events that occur. John Fawkner Private Hospital has many strategies in place to prevent adverse transfusion events from occurring.

This graph shows the number of patients at John Fawkner Private Hospital that had a transfusion with NO significant adverse event. The rate for the past years is shown in the coloured bars. This is compared to the rate of transfusion events in other Australian hospitals (the grey bar). The graph shows that patients at John Fawkner Private Hospital are less likely to have an adverse transfusion event, compared with other Australian hospitals.

What we are doing to reduce the risk of adverse transfusion events

The following strategies are used:

  • National policies and procedures, consistent with national evidence based guidelines for pre-transfusion practices, prescribing and administration of blood
  • Avoiding unnecessary blood transfusions by use of alternative medications, treatments and non-blood treatments.
  • Identifying any risk factors for adverse reactions, before the transfusion commences.
  • Careful cross-matching of blood groups to make sure no errors occur.
  • Education and competency training for nursing staff in blood transfusion administration.
  • Patient education and provision of written materials explaining blood transfusions.
  • Individual reporting: Examining each adverse transfusion event to determine why it occurred and how to prevent this happening again.
  • Careful monitoring of patients and taking close observations during administration of a blood transfusion.
  • Working closely with the pathology laboratory that provides the blood.
  • Monitoring and auditing compliance to transfusion policies and procedures
  • There is a robust system for reporting and feedback for adverse events, incidents and near misses relating to transfusion practice.
  • Transfusions are not conducted at every Healthscope hospital. If a hospital does not have sufficient experience in conducting a transfusion, the patient is moved to another hospital for this procedure.
  • Healthscope has a National Transfusion Governance Committee that oversees best practice standards for transfusion management in all hospitals – and also reviews adverse events nationally so that all hospital can learn from them.

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.

To see the emergency waiting times for John Fawkner Private Hospital, see below.

Emergency Department Waiting Times - Triage Catagory 1: Patients Seen Immediately


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.

Many patients who come to John Fawkner Private Hospital have an operation in our theatres. Most operations require some kind of anaesthetic, administered by an Anaesthetist. After waking up from an anaesthetic, patients require close monitoring to make sure that their pain and conscious state, and observations such as blood pressure are all back to normal. This typically happens in the Recovery Unit. After a large operation, such as a heart bypass operation, an admission to the Intensive Care Unit may be planned, to allow close monitoring by specialised equipment. On rare occasions, other patients may have an unexpected reaction to an anaesthetic, and may require an unplanned admission to the Intensive Care Unit for monitoring.

Tracking the number of patients who have an admission to Intensive Care after an operation is one way that we can judge the quality of hospital care. Good nursing care can help reduce the rate of unplanned admission to Intensive Care and good monitoring can pick up any problems early.

This graph shows the percentage of patients admitted to John Fawkner Private Hospital that have required an unplanned admission to the Intensive Care Unit within 24 hours of their operation. The rate for the past 5 years is shown in the green bars. This is compared to the rate of “unplanned admission to Intensive Care” in other Australian hospitals (the grey bar).

This graph shows that patients admitted to John Fawkner Private Hospital are more likely to have an unplanned admission to Intensive Care compared with other Australian hospitals.

What we’re doing to further reduce unplanned admission to Intensive Care

Improvement strategies may vary from hospital to hospital. Examples are:

  • We review each admission to Intensive Care to check if there were any preventable factors
  • Before operations, the nurses, doctors and anaesthetists carefully check each patient’s risks for anaesthetic.
  • The Theatre and Recovery Units use a consistent process for discharging patients either to the ward or to home, to make sure they have fully recovered from the anaesthetic.
  • If a patient has additional risk factors, sometimes an Intensive Care bed is planned and booked in advance, to make sure the post-operation monitoring is the best possible.
  • We monitor this data to make sure that the rate of unplanned admission to Intensive Care is not increasing.

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 John Fawkner Private 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 John Fawkner Private Hospital that have required an unexpected and unplanned readmission to hospital within 28 days of their first admission. The rate for the past 5 years is shown in the blue bars. This is compared to the rate of “unplanned readmission” in other Australian hospitals (the grey bar). A recent analysis from the NSW Bureau of Health Information, reports that the unplanned readmission rate in NSW public hospitals was 6.8% and rising, 18 to 40% higher than in previous years.

The graph shows that patients admitted to John Fawkner Private Hospital are slightly more 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 re-admission 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 re-admission is not increasing.

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 5 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.

For many operations and procedures (such as arthroscopy, colonoscopy) that are performed at John Fawkner Private Hospital, an overnight stay is not required. Patients are admitted a few hours before their operation or procedure, and go home on the same day, after they have recovered from their anaesthetic. After waking up from an anaesthetic, patients require close monitoring to make sure that their pain and conscious state, and observations such as blood pressure are all back to normal. This typically happens in the Recovery Unit. On rare occasions, patients may have an unexpected reaction to an anaesthetic or procedure, and may require an unplanned overnight stay in hospital, or transfer to another hospital

Tracking the number of day patients who have an unplanned overnight stay after an operation is one way that we can judge the quality of hospital care. Good planning and medical care can help reduce the rate of unplanned overnight admissions.

This graph shows the percentage of day patients admitted to John Fawkner Private Hospital that have required an unplanned overnight stay or transfer to another hospital. The rate for the past 5 years is shown in the blue bars. This is compared to the rate of “unplanned admission to Intensive Care” in other Australian hospitals (the grey bar).

The graph shows that patients admitted to John Fawkner Private Hospital are less likely to have an unplanned admission to Intensive Care compared with other Australian hospitals.

What we’re doing to further reduce unplanned overnight admission

Improvement strategies may vary from hospital to hospital. Examples are:

  • We review each unplanned transfer or overnight admission to check if there were any preventable factors
  • Before operations, the nurses, doctors and anaesthetists carefully check each patient’s risks for the operation and recovery.
  • Pre-admission clinics are used to make sure the patient and staff are as prepared as possible for the operation or procedure.
  • The Theatre and Recovery Units use a consistent process for discharging patients home, to make sure they have fully recovered from the operation.
  • If a patient has additional risk factors or requires more intensive monitoring, sometimes an overnight ward bed is planned and booked in advance, to make sure the post-operation monitoring is the best possible.
  • We monitor this data to make sure that the rate of unplanned transfer and admission to hospital is not increasing.

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.

If you would like more information about the pros and cons of public reporting, see: Public Reporting Literature

Our Assistance

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