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Prince of Wales Private Hospital

MyHealthscope - Quality and Safety

At Prince of Wales Private Hospital, we take quality and safety seriously.

To provide you with information about our performance, Prince of Wales Private Hospital publishes data which 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 Prince of Wales Private 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.

Prince of Wales 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

The Prince of Wales Private Hospital National Safety and Quality Heath Service Standards (NSQHSS) successful accreditation survey was conducted in July 2016 by the Australian Council on Health Care Standards (ACHS). The surveyors made particular mention of all the staff being uniformly very proud of their organisation, the evident robust quality frameworks and the attention to quality and safety. Prince of Wales Private Hospital met all NSQHSS core criteria with three Met with Merits awarded, two in NSQHSS 1 for staff awareness of their safety and quality responsibilities and the support provided and one in NSQHSS 3 for our infection control governance systems.


Other Awards

In addition to accreditation, Prince of Wales Private Hospital is proud of the recognitions of excellence bestowed on its hospitals and staff. Examples of recent awards are:

2013 Service Excellence & Exceptional Customer Service – Environmental Serviceso 2013 Aspiration Category – Ward 6 North

2014 Teamwork and Integrity- Individual Nerida Russell-Green

2014 Outstanding Achievement in Responsibility - Catering Department

2014 Highly Commended– Individual Aspiration - Stevi Jones NUM

2014 PoWPH Best Patient Centered Care Performance "

2015 Highly Commended – Team Work and integrity Shane Valentine B&AC Manager

Prince of Wales Private 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 Prince of Wales Private Hospital. Two of the most important are:

  • Staphylococcus Aureus Bacteraemia – also known as SB. 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 Prince of Wales Private Hospital. The coloured bars represent Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private 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?

Prince of Wales Private 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 Prince of Wales Private 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. 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 and doctors at Prince of Wales 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. Unfortunately, hand hygiene is sometimes not well performed by health care workers.


What is Prince of Wales 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. Prince of Wales 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 Prince of Wales 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 during spot audits at Prince of Wales Private Hospital during the past 4 years compared with the Australian benchmark of 80%.

Staff at Prince of Wales Private Hospital on average have a high rate of compliance with hand hygiene. The graph also shows that the hospital’s hand hygiene rate has improved over time. 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 Prince of Wales 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, cleaners and other hospital staff.


The graph on the left shows which groups were audited. The graph on the right shows the hand hygiene rate for different staff within the hospital. The graph shows that compliance rates for nurses are 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 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 Prince of Wales 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 doctors staff, patients, families and visitors.
  • Monitoring the type of soap/hand sanitiser used, to minimise skin irritation
  • Individual staff sanitisers provided in critical care areas
  • 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 Prince of Wales 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

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 Prince of Wales Private 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 Prince of Wales Private Hospital have a lower rate of falls than patients in other Australian hospitals.

The number of falls at Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private Hospital are less likely to develop a pressure injury than patients in other Australian hospitals.

What are we doing with this data?

Prince of Wales Private Hospital 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. Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private 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?

    Prince of Wales Private 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

      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 Prince of Wales Private 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 Prince of Wales Private 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?

      Prince of WalesPrivate Hospital 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

        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 Prince of Wales Private 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 Prince of Wales Private 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?

        Prince of Wales Private Hospital 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 Prince of Wales Private Hospital. The coloured bars represent Prince of Wales Private 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 Prince of Wales Private Hospital are slightly more likely to have an unexpected return to theatre compared with patients in other Australian hospitals.

          What are we doing with this data?

          Prince of WalesPrivate 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

            Many operations and procedures performed at Prince of Wales Private 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 Prince of Wales Private 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 Prince of Wales Private Hospital are less likely to have an unplanned overnight stay compared with patients in other Australian hospitals.

            What are we doing with this data?

            Prince of WalesPrivate 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

              Childbirth is a natural, normal event, and although you may choose to have your baby in hospital, it doesn’t mean that medical intervention will be required. Most babies are born without any difficulties and with the encouragement and support from Prince of Wales Private Hospital staff. However, sometimes intervention by the obstetrician, paediatrician or midwife may be required in order for a safe outcome for your baby.

              After a baby is born, the hospital staff will do a thorough check of all aspects of the baby’s health, measuring their Apgar Score to check the baby’s breathing, heart rate, colour, activity and temperature. Some babies may require closer monitoring, help with breathing, body temperature, or further investigations. This sometimes happens in the Neonatal Intensive Care Unit. “Neonatal” means “around the time of birth”. This is a specialised unit with staff that are experts in dealing with newborn babies. In some cases, if an unborn baby has a specific medical condition, an admission to the Neonatal Intensive Care Unit may be planned even before delivery of the baby. On rare occasions, babies may be born with an unexpected medical condition, and may require an unplanned admission to the Neonatal Intensive Care Unit for treatment.

              Tracking the number of patients who have an unplanned admission to the Neonatal Intensive Care Unit after birth is one way that we can judge the quality of hospital care. Good medical and nursing care during delivery and during the months of pregnancy, can help reduce the rate of unplanned admissions to Neonatal Intensive Care. Good monitoring during labour can pick up any problems early.

              This graph shows the percentage of babies born in Prince of Wales Private Hospital that have required an unplanned admission to the Neonatal Intensive Care Unit. The rate for the past 3 years is shown in the pink bars. This is compared to the rate of “unplanned admission to Intensive Care” in other Australian hospitals (the grey bar).

              The graph shows that babies born in Prince of Wales Private Hospital are less likely to have an unplanned admission to the Neonatal Intensive Care compared with other Australian hospitals.


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

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

              • We review each admission to Neonatal Intensive Care to check if there were any preventable factors
              • Before a baby is born, and during the pregnancy, the midwives and obstetricians carefully assess and monitor the mother and baby for any risk factors, such as gestational (pregnancy) diabetes.
              • The Theatre and Recovery Units use a consistent process for discharging mothers and babies from the delivery suite to the ward, to make sure they have fully recovered from the birth.
              • If a mother or baby has additional risk factors, sometimes a Neonatal Intensive Care bed is planned and booked in advance, to make sure the post-natal monitoring is the best possible.
              • We monitor this data to make sure that the rate of unplanned admission to Neonatal Intensive Care is not increasing

              Following the birth of a baby, the doctor or midwife assesses the baby's overall condition, including heart rate, breathing, responsiveness, activity and skin colouration. A score known as the Apgar score is used to measure these signs at one minute and again at five minutes after birth. A healthy Apgar score is defined as 7 or above. The highest possible Apgar score is 10.

              The graph below shows the percentage of babies who have a healthy Apgar score at five minutes after birth. The coloured bars represent Prince of Wales Private Hospital's rate. This is compared to the rate at other Australian hospitals, shown in the grey bar.

              This graph shows that the percentage of babies born with a healthy Apgar score is higher at Prince of WalesPrivate Hospital than at other Australian hospitals.


              More Information

              The table below lists the five Apgar signs. Each of the areas is given a score of 0, 1 or 2, to make a total Apgar score of up to 10 points.

              The birth of a baby is a very exciting time, and we want to provide our patients with the best possible hospital experience. Many new mothers choose to remain in hospital as long as possible after giving birth, particularly for a first baby. However, patients are free to go home earlier if they would like to.

              The number of days women typically spend in hospital after having a baby will depend on whether they have had a vaginal delivery or a Caesarean section. In most cases, patients stay a little longer after a Caesarean section.

              The graph below shows the average length of stay for childbirth at Prince of Wales Private Hospital. The length of stay in other Australian private and public hospitals is also shown.

              This graph shows that women having a baby at Prince of Wales Private Hospital and other Australian private hospitals stay in hospital longer than women in Australian public hospitals.

              Prince of Wales 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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