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Pine Rivers Private Hospital

MyHealthscope - Accreditation, Quality and Safety

Measures of hospital performance

At Pine Rivers Private Hospital, we take quality and safety seriously.

To help patients make informed decisions, Pine Rivers 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 Pine Rivers 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.

Pine Rivers 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 Pine Rivers Private Hospital for their organisation wide survey in 2017. Pine Rivers Private Hospital has maintained accreditation under the National Safety and Quality Health Service Standards.

Patient mental health is measured on admission to Pine Rivers Private Hospital and again on discharge so that we can measure the improvement made. Patients demonstrate improvement in their mental health after treatment at Pine Rivers Private Hospital. We use the HoNOS (Health of the Nation Outcome Scales) to measure the health of patients with mental illness. This is an established scale, used worldwide.


HoNOS Scores

This graph shows the improvement in patients after mental health treatment at Pine Rivers Private Hospital. The dark coloured bar shows mental health problems on admission and the pale coloured bar shows that these problems have decreased on discharge. Pine Rivers Private Hospital achieves improvement outcomes similar to other private hospitals.


MHQ-14 Scores

Importantly, we also ask the patients whether they think their mental status has improved during their hospital admission. The MHQ–14 (Mental Health Questionnaire) is completed by patients and asks questions about symptoms of fatigue, anxiety and depression and the impact of those symptoms in daily life.

This chart shows patient-self-assessed mental health ratings on admission (dark coloured bars) and discharge (pale coloured bars). Patients at Pine Rivers Private Hospital achieve self-assessed improvement better than patients at other private hospitals.

For more information on how to measure changes in mental health, refer to this excellent brochure produced by the Royal Australian and New Zealand College of Psychiatrists.

For more information on:


What we are doing to continually improve our patients’ mental health outcomes

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

  • Patients are seen by a multidisciplinary team, including expert nursing and allied health members
  • Group therapy, counselling and other kinds of therapy are scheduled
  • Patient medication is reviewed to make sure it is optimal
  • Family and carer involvement in the decision-making and planning of treatment

Pine Rivers 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 Pine Rivers 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 Pine Rivers 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 Pine Rivers Private Hospital for the year ending June 2016 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 Pine Rivers Private Hospital on average have a very low number of infections.

This graph shows the number of Clostridium Difficile infections at Pine Rivers 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 Pine Rivers 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 Pine Rivers 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 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

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 Pine Rivers 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 Pine Rivers 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. Pine Rivers 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.

Although mental health hospitals are not yet required or able to submit data to hand hygiene australia, all healthscope mental health hospitals have started to collect this information, as we know that hand hygiene is important in every setting.

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 Pine Rivers 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 Pine Rivers Private compared with the Australian national benchmark of 80%. Staff at Pine Rivers Private Hospital on average have a similar rate of compliance with hand hygiene than the benchmark.

The more hand hygiene moments are audited, the more reliable our figures. This figure shows how many hand hygiene moments were audited at Pine Rivers 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 nurses and doctors are very high.




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 Pine Rivers 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 Pine Rivers 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.

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 Pine Rivers 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 Pine Rivers Private Hospital for the past 5years, compared with the industry rate. Falls are presented as a percentage of patient days – allowing us to compare Pine Rivers Private Hospital with other hospitals of a different size. Patients at Pine Rivers Private 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 Pine Rivers 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.

Brochure: Preventing Falls at Home
Video: Speak Up Reduce Your Risk of Falling

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 Pine Rivers 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 relapse in depression symptoms after his or her initial hospital stay. Unfortunately, more patients have an unplanned readmission for a mental health condition (on average 6.4% in Australian hospitals) than for an acute medical/surgical condition (1.1% in Australian hospitals).

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 Pine Rivers Private Hospital in 2016 that required an unexpected and unplanned readmission to hospital within 28 days of their first admission.

The graph shows that patients admitted to Pine Rivers Private Hospital are less likely to have an unplanned readmission compared with other Australian mental health hospitalsWhat 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 outpatient programs and ongoing appointments, eg. with Counsellor and General Practitioner
  • We monitor this data to make sure that the rate of unplanned readmission 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.

Pine Rivers 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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