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The Victorian Rehabilitation Centre

MyHealthscope - Accreditation, Quality and Safety

Measures of hospital performance

At The Victorian Rehabilitation Centre, we take quality and safety seriously.

To help patients make informed decisions, The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre, 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.

The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre for their organisation wide survey in November 2014 compared to other Australian hospitals. The Victorian Rehabilitation Centre maintained accreditation under the National Safety and Quality Health Service Standards.

Other Awards

In addition to accreditation, The Victorian Rehabilitation Centre is proud of the recognitions of excellence bestowed on its hospitals and staff. Examples of recent awards are:

2010 Healthscope Service Excellence Awards

The Billing Team
The Victorian Rehabilitation Centre (VIC)
Sharon won the Healthscope Staff Excellence Award in 'Financial Responsibility' for outstanding achievements in the financial management of the Victorian Rehabilitation Centre

Patient abilities, mobility and independence are measured on admission to The Victorian Rehabilitation Centre and again on discharge so that we can measure the improvement made. Patients demonstrate improvement in their abilities, mobility and independence after treatment at The Victorian Rehabilitation Centre. We use the FIM™ (Functional Independence Measure) to measure the success of rehabilitation. This is an established scale, used worldwide.

Improvement in patient abilities will depend on factors such as patient age, severity of condition on admission and other medical problems such as diabetes or dementia. The graphs below show some of these factors.

This chart shows that patients at The Victorian Rehabilitation Centre are on average slightly older than patients in other Australian hospitals.

This chart shows that fewer patients at The Victorian Rehabilitation Centre have severe impairments on admission than patients in other Australian hospitals.

See a definition for severity


Stroke Rehabilitation

This graph shows the average improvement in patients after stroke rehabilitation at The Victorian Rehabilitation Centre. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Patients at The Victorian Rehabilitation Centre have similar scores on both admission and discharge as patients in other Australian hospitals.


Orthopaedic Fracture Rehabilitation

This graph shows the average improvement in patients at The Victorian Rehabilitation Centre following rehabilitation after a broken bone. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Patients at The Victorian Rehabilitation Centre have higher scores on both admission and discharge than patients in other Australian hospitals.


Rehabilitation for Hip, Knee or Shoulder Replacement

This graph shows the average improvement in patients at The Victorian Rehabilitation Centre following rehabilitation for other neurological (brain) conditions such as Parkinson’s Disease and Multiple Sclerosis. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Patients at The Victorian Rehabilitation Centre have similar scores on both admission and discharge than patients in other Australian hospitals.


Rehabilitation for Other Neurological Conditions

This graph shows the average improvement in patients at The Victorian Rehabilitation Centre following rehabilitation for other neurological (brain) conditions such as Parkinson’s Disease and Multiple Sclerosis. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Patients at The Victorian Rehabilitation Centre achieve outcomes similar to those of patients in other Australian hospitals.


What we are doing to continually improve our patients’ rehabilitation

  • Individual and group therapy – individualised therapy time which may include practising tasks of daily living
  • Multi-disciplinary team assesses and works with patient to set and meet goals
  • Use of Functional Electrical Stimulation (FES) to improve strength and function in stroke patients
  • Depression screening for all stroke patients (if depressed not able to participate fully in rehabilitation)
  • Swallowing and speech/language therapy by Speech Pathologists

The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre. 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre on average have a very low number of infections.

This graph shows the number of Clostridium difficile infections at The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre, 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre 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. The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre for the past 4 years compared with the Australian national benchmark of 80%.

Staff at The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre 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.

This 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 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre, 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre for the past 5 years, compared with other Australian non-acute private hospitals. Falls are presented as a percentage of patient days – allowing us to compare The Victorian Rehabilitation Centre with other hospitals of a different size. The Victorian Rehabilitation Centre has a similar falls rate to that of other hospitals.

98% of falls at The Victorian Rehabilitation Centre in 2016 were minor in nature and did not require intervention.

The hospital has investigated the higher rate and introduced some new strategies that will reduce the number of falls in the future. These are listed below.

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

Patients who are undergoing rehabilitation are encouraged to be up on their feet as part of their therapy and treatment. Sometimes, this means that patients are more likely to have falls in rehabilitation hospitals, than in medical/surgical hospitals. We use the following strategies to prevent 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
  • Use of a “traffic light” system where patients are given a red, orange or green tag, which alerts staff to whether the patient is at risk of falling.


How can you help?

At The Victorian Rehabilitation Centre, 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

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 The Victorian Rehabilitation Centre 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.

The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre are more likely to develop a pressure injury compared with other Australian hospitals.


After a successful hospital stay, the most important task for patients, families and staff is preparing for a successful discharge home. It is disappointing for everyone if a patient requires an unexpected readmission into hospital.

Tracking the number of patients who experience unplanned readmissions to The Victorian Rehabilitation Centre after a previous hospital stay is one way that we can judge the quality of hospital care. One example of an unplanned readmission would be someone who is readmitted to the hospital for a surgical wound infection that occurred after his or her initial hospital stay.

It is important to note that unplanned hospital readmissions may or may not be related to the previous visit, and some unplanned readmissions are not preventable. Good discharge plans can help reduce the rate of unplanned readmissions by giving patients the care instructions they need after a hospital stay and by helping patients recognise symptoms that may require immediate medical attention.

This graph shows the percentage of patients admitted to The Victorian Rehabilitation Centre 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 The Victorian Rehabilitation Centre are less likely to have an unplanned readmission compared with other Australian hospitals.

There is a limitation to this data. Currently no unique patient identifier exists that would allow us to measure unplanned readmissions to a different hospital. Therefore the unplanned readmission rates presented in this graph represent patients re-admitted to the same hospital only.

What we are doing to further reduce unplanned readmission rates

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

  • We review each case of readmission to check if there were any preventable factors.
  • Check each patient’s risk for readmission
  • Use a consistent process for discharging patients that includes making sure patients understand their medications and other instructions
  • Arranging prompt follow up care and ongoing appointments, eg. with Physiotherapist and General Practitioner
  • We monitor this data to make sure that the rate of unplanned readmission is not increasing.

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.

Healthscope 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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