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Mount Hospital

MyHealthscope - Quality and Safety

At Mount Hospital, we take quality and safety seriously.

To provide you with information on our performance, Mount Hospital publishes data that reflects the quality and safety of our services. This is only one part of our program to continually maintain and improve our high standards.

At Mount Hospital, quality is not just one simple measure. It includes many aspects of care and of a patient's experience.

Please click on the menu below to view data for each of the indicators we publish.

All Healthscope hospitals are fully accredited against one of two accreditation schemes accepted by the Australian Government. Accreditation is conducted against either the Australian Council on Health Care Standards (ACHS) Evaluation and Quality Improvement (EQuIP) standards or ISO 9001 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 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


At the recent accreditation survey Mount Hospital maintained accreditation under the National Safety and Quality Health Service Standards.


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:

2011 Healthscope Excellence Awards

Narelle Hickey
Registered Nurse (Intensive Care Unit)
Mount Hospital (WA)
Narelle’s passion for patient and family centered practice has helped numerous patients achieve optimal results. Having worked mainly in the medical oncology ward before moving to ICU, Narelle shows great innovation and determination to support patients clinically and emotionally. Narelle instils a sense of team collaboration through initiating referrals and consultations with allied health staff to ensure continuity of care.


2011 Australian Water Association's Waterwise Business Award (Western Australian Branch)

Mount Hospital was selected as joint winner for 2011 for our initiatives implemented ensure water efficiency and saving. In addition, the Water Corporation has awarded the Mount Hospital with a certificate of recognition for great water efficiency and savings achieved in the 2011/2012 financial year.


Staff Long Service Awards

Each year we acknowledge staff who have devoted a number of years to working at the Mount Hospital. At the end of 2012 we recognised 108 long term staff members of whom achievied 10, 15, 20, 25, 30 and 35 years of service for their dedication and loyalty and the contribution they make to the hospital. The strength of Mount Hospital lies in all our staff who are focused on the one reason for achieving our best – our patients.

At Mount Hospital, we measure the ability, mobility and independence of patients on admission and again on discharge to see how they are improving. We use the internationally recognised FIM™ (Functional Independence Measure), a scale which measures the success of rehabilitation.

It is important to note that rehabilitation outcomes are not solely dependent on the quality of care provided. Patient-specific factors such as age, severity of condition and presence of other health issues can influence how much improvement is achieved.

This chart shows that patients at Mount Hospital are on average younger than patients in other Australian hospitals.

The chart below shows the percentage of patients with a severe impairment on admission. The coloured bars represent Mount Hospital's rate. This is compared to the rate in other Australian hospitals, shown in the grey bar.

This chart shows that fewer patients at Mount Hospital have severe impairments on admission than in other Australian hospitals.

See a definition for severity here.

Rehabilitation for Hip, Knee or Shoulder Replacement

The graph below shows the improvement in patients after rehabilitation for a joint replacement. The dark coloured bars represent patients' abilities on admission to Mount Hospital. The pale coloured bars represent patients' abilities on discharge. This is compared to the outcomes at other Australian hospitals, shown in the grey bars.

This graph shows that rehabilitation patients with a joint replacement at Mount Hospital achieve similar outcomes as patients in other Australian hospitals.

What are we doing with this data?

  • a multi-disciplinary team approach, including expert nursing and allied health professionals
  • individual and group therapy, often including practice of tasks of daily living
  • use of Functional Electrical Stimulation (FES) to improve strength and function in stroke patients
  • depression screening for all stroke patients to support full participation in rehabilitation
  • swallowing and/or speech/language therapy with a Speech Pathologist

    Mount Hospital follows strict infection control procedures, and staff take every precaution to prevent infections. Specialised infection control staff collect and analyse data on infections in order to identify and implement best practices to reduce infection rates.

    Patients with weakened immune systems, with wounds and with invasive devices such as drips are at greater risk of infection than the general public.

    There are several types of infections that we closely monitor at Mount Hospital. Two of the most important are:

    • Staphylococcus Aureus Bacteraemia – also known as SAB. This is a serious infection caused by bacteria entering the blood stream.
    • Clostridium Difficile - also known as C Diff. This is an infection of the bowel that causes diarrhoea.

    The graph below shows the number of Staphylococcus Aureus infections at Mount Hospital. The coloured bars represent Mount Hospital's rate. This is compared to the Australian Government target, shown in the grey bar. The national benchmark for SAB is no more than 2 cases per 10,000 days of patient care.

    This graph shows that the rate of SAB infections at Mount Hospital is very low and lies well below the Australian government target.

    The graph below shows the number of Clostridium Difficile infections. The coloured bars represent Mount Hospital's rate. This is compared to the rate in other Australian hospitals, shown in the grey bars. The industry rate varies from 2 to 3 cases per 10,000 days of patient care.

    This graph shows that the number of Clostridium Difficile infections at Mount Hospital is very low and lies well below the industry rate.

    To find out how we generated this data, see: Infection Rate Formulas

    What are we doing with this data?

    Mount Hospital employs a variety of strategies to prevent infections. These include:

    • auditing how often staff wash their hands using soap and water or hand sanitiser
    • using gloves and specialised sterile equipment
    • assigning a dedicated Infection Control Nurse responsible for educating staff and implementing infection control strategies
    • using specialised disinfectants when cleaning facilities
    • following national guidelines for high level disinfection and sterilisation processes
    • placing hand sanitiser dispensers in public areas throughout the hospital so that they are readily accessible to staff, patients and visitors

    What can you do to help?

    At Mount Hospital, patients and visitors are part of the health care team. There are a number of things you can do to reduce the risk of infection for yourself and others:

    • 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. Clean your hands afterwards – every time!
    • If you don't have a tissue available, cough or sneeze into your elbow, not your hand.
    • As a patient, 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 for 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 your healthcare worker if the area around any drips, 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

    • Don't visit if you have an illness such as a cough, cold or gastroenteritis ('gastro').
    • 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:

    Hand Hygiene is another name for hand washing or cleaning. Good hand hygiene is an important part of infection control. Germs can survive on unwashed hands for over an hour, and we can unknowingly transmit bacteria and viruses to others.


    All Healthscope staff are required to frequently wash their hands with soap and water or with waterless hand sanitiser. Both are equally effective. We follow the World Health Organisation's guidelines for hand hygiene, which specify the following times when health care staff must wash their hands:
    • before touching a patient
    • after touching a patient
    • before a procedure
    • after a procedure
    • after touching a patient’s belongings or surroundings

    At Mount Hospital, we use auditors who are accredited by Hand Hygiene Australia to record whether or not hand hygiene has been performed correctly. The graph below shows the levels of hand hygiene compliance. The coloured bars represent Mount Hospital's rate. This is compared to the Australian national benchmark of 80%, shown in the grey bar.


    This graph shows that hand hygiene compliance at Mount Hospital has been improving in recent years.

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

    The first graph below on the left shows which groups were audited. The graph on the right shows the hand hygiene compliance rate for different staff within the hospital. It shows that the compliance rate for nurses is higher than for other staff.

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

    What are we doing with this data?

    Mount Hospital employs a variety of strategies to improve hand hygiene compliance. These include:

    • ongoing education programs for staff about infections and hand hygiene
    • a designated Infection Control Nurse responsible for educating staff and implementing infection control strategies
    • placement of hand sanitiser dispensers in convenient areas throughout the hospital, including hallways and patient rooms
    • use of specially designed washbasins where water can be turned on and off without touching the tap

    What can you do to help?

    At Mount Hospital, patients and visitors are part of the health care team. Good hand hygiene is the most important way in which patients and visitors can prevent the spread of infection in hospital. There are a number of things you can do:

    • 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

    Falls are a leading cause of hospital-acquired injury and frequently prolong or complicate hospital stays. Patients may experience a fall because they are weakened by a medical condition or after an accident or injury.

    The graph below shows the percentage of patients who have had a fall. The coloured bars represent Mount Hospital's rate. This is compared to the rate of falls at other Australian hospitals, shown in the grey bar.

    This graph shows that patients at Mount Hospital have a lower rate of falls than patients in other Australian hospitals.

    The number of falls at Mount Hospital is much lower than expected for a hospital of its size. Whilst this may appear to be positive, it is believed that staff are not always reporting every fall in the incident reporting system. Reporting is important, as it allows us to analyse reasons for falls or near-falls and focus on preventing them in future. Education has been carried out at Mount Hospital to ensure that all staff are aware of the requirement for reporting of any fall.

    See details on: How we work out our falls rate
    For a discussion on the data, see: Limitations of data

    What are we doing with this data?

    • risk assessments to identify patients at risk of falling
    • ongoing staff education on falls prevention
    • patient education on prevention of falls in hospital and at home
    • use of safety equipment such as lifting hoists, walking aids and chair or bed sensors that alert staff when a patient at risk of falling gets up unassisted
    • review of each fall to assess if there were any preventable factors

    What can you do to help?

    At Mount Hospital, patients and visitors are part of the health care team. You may like to print a brochure containing handy hints about preventing falls. You can also watch a helpful video.

    Brochure: Don't Fall For It

    Video: Speak Up Reduce Your Risk of Falling

    Pressure injuries - commonly known as bed sores - are areas of skin damage caused by prolonged pressure. They can range in severity from an area of reddened skin to ulcers with underlying tissue damage.

    Pressure injuries can sometimes occur when a patient remains in one position for a long period. Certain people are at increased risk of developing pressure injuries, such as the elderly, people who are bedbound or have poor mobility and people with chronic conditions like diabetes.

    This graph below shows the number of patients who have developed a pressure injury during their admission to hospital. The coloured bars represent Mount Hospital's rate. This is compared to the rate of pressure injuries in other Australian hospitals, shown in the grey bar.

    This graph shows that patients at Mount Hospital are less likely to develop a pressure injury than patients in other Australian hospitals.

    What are we doing with this data?

    MountHospital employs a variety of strategies to minimise the risk of patients developing pressure injuries. These include:

    • risk assessments to identify patients who are susceptible to pressure injuries
    • ongoing education for nursing staff in pressure injury identification, prevention and management
    • patient education on prevention of pressure injuries in hospital and at home
    • use of pressure-relieving devices such as special mattresses, cushions, wedges, sheepskins, water-filled supports, contoured or textured foam supports, heel elevators and supports filled with gel or beads
    • regularly changing patients' position and encouraging walking or movement if possible
    • referral to a wound management consultant if a pressure injury is identified
    • review of each pressure injury acquired in hospital to assess if there were any preventable factors

      A blood transfusion is the transfer of blood or blood products such as platelets or plasma into a patient's vein, usually via an intravenous(IV) cannula. Transfusions may be necessary when a patient

      • has lost a large amount of blood
      • is unable to produce parts of their own blood
      • has blood cells that are not functioning properly

      Transfusions are carried out on doctor's orders by trained professional staff, in accordance with the National Safety and Quality Health Service Standards and with the patient's consent. Mount Hospital audits this on a regular basis.

      A blood transfusion can be lifesaving or significantly improve quality of life. Australia has one of the safest blood supplies in the world, but no blood transfusion is completely without risk. While adverse events are rare, they may include:

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

      The graph below shows the number of patients who had a transfusion with no significant adverse event. The coloured bars represent Mount Hospital's rate. This is compared to the rate of successful transfusion events in other Australian hospitals, shown in the grey bar.


      This graph shows that patients at Mount Hospital are less likely to have an adverse transfusion event compared with patients in other Australian hospitals.

      Some useful resources about blood transfusions are available here.

      What are we doing with this data?

      Mount Hospital employs a variety of strategies to reduce the risk of adverse transfusion events. These include:

      • avoiding unnecessary blood transfusions by use of medications 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
      • ongoing training for nursing staff involved in blood transfusion administration
      • patient education and provision of written materials explaining blood transfusions
      • careful monitoring of patients during administration of a blood transfusion
      • working closely with the pathology laboratory that provides the blood
      • review of each adverse transfusion event to assess if there were any preventable factors

      Healthscope has a National Transfusion Governance Committee that oversees best practice standards for transfusion management in our hospitals and reviews adverse events nationally, so that all hospitals can learn from them.

        Following surgery, all patients require close monitoring. This monitoring typically happens in the Recovery Unit. For some major operations, such as heart surgery, an admission to the Intensive Care Unit may be planned to allow monitoring with specialised equipment.

        Occasionally, a patient may have an unexpected reaction to the anaesthetic or a complication from surgery and will require an unplanned admission to Intensive Care.

        The graph below shows the percentage of patients who have required an unplanned admission to the Intensive Care Unit within 24 hours of their operation. The coloured bars represent Mount Hospital's rate. This is compared to the rate of unplanned admission to Intensive Care in other Australian hospitals, shown in the grey bar.

        This graph shows that patients admitted to Mount Hospital are less likely to have an unplanned admission to Intensive Care compared with patients in other Australian hospitals.

        What are we doing with this data?

        MountHospital employs a variety of strategies to minimise unplanned admissions to Intensive Care. These include:

        • pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
        • advance bookings of Intensive Care beds for patients who have specific risk factors
        • review of each unplanned admission to Intensive Care to assess if there were any preventable factors

          Many operations and procedures performed at Mount Hospital do not require an overnight stay. For minor procedures like colonoscopies and arthroscopies, patients are usually admitted a few hours before their procedure and go home later the same day, after they have recovered from the anaesthetic.

          Occasionally, a patient may have an unexpected reaction to the procedure or anaesthetic and will require an unplanned overnight stay or transfer to another hospital.

          The graph below shows the percentage of day patients who have required an unplanned overnight stay or transfer to another hospital. The coloured bars represent Mount Hospital's rate. This is compared to the rate of unplanned overnight stays in other Australian hospitals, shown in the grey bar.

          This graph shows that patients admitted to Mount Hospital are less likely to have an unplanned overnight stay compared with patients in other Australian hospitals.

          What are we doing with this ata?

          Mount Hospital employs a variety of strategies to minimise unplanned overnight stays. These include:

          • pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
          • careful monitoring of patients during recovery
          • use of a consistent process for discharging patients home, to make sure they have fully recovered from the procedure
          • review of each unplanned overnight stay to assess if there were any preventable factors

            Following discharge from hospital, patients may sometimes require an unplanned readmission. There are many reasons why a patient may need to return to hospital, such as a surgical wound infection that occurred after the initial hospital stay.

            Good discharge planning can help reduce the rate of unplanned readmissions. This includes making follow-up arrangements, providing patients with clear care instructions and helping them recognise symptoms that require immediate medical attention.

            The graph below shows the percentage of patients who have required an unplanned readmission to hospital within 28 days of their first admission. The coloured bars represent Mount Hospital's rate bars. This is compared to the rate of unplanned readmissions in other Australian hospitals, shown in the grey bar.

            This graph shows that patients admitted to Mount Hospital are less likely to have an unplanned readmission compared with patients in other Australian hospitals.

            Please note: The unplanned readmission rates presented in this graph only include patients who have been readmitted to the same hospital. Currently, we have no way of measuring unplanned readmissions to a different hospital.

            What are we doing with this data?

            MountHospital employs a variety of strategies to minimise unplanned readmissions. These include:

            • discharge processes which ensure that patients understand their medications and any post-operative instructions
            • arranging appropriate follow-up care and ongoing appointments, e.g. with the General Practitioner or Physiotherapist
            • review of each unplanned readmission to assess if there were any preventable factors

              Following a procedure in the operating theatre, patients sometimes need an unplanned second operation. This is called 'return to theatre”. There are many reasons why a patient may require a further operation, such as complications from the first procedure or an unrelated matter.

              The graph below shows the percentage of patients who have required a return to theatre after having an operation at Mount Hospital. The coloured bars represent Mount Hospital's rate. This is compared to the rate of return to theatre in other Australian hospitals, shown in the grey bar.

              This graph shows that patients undergoing surgery at Mount Hospital are less likely to have an unexpected return to theatre compared with patients in other Australian hospitals.

              What are we doing with this data?

              Mount Hospital employs a variety of strategies to minimise unplanned returns to theatre. These include:

              • pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
              • careful monitoring of patients in recovery
              • review of all unplanned returns to theatre to assess if there were any preventable factors

                Mount 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.


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