Waverley Private Hospital
Part of Ramsay Health Care

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CLINICAL QUALITY and SAFETY

Waverley Private Hospital is focused on the delivery of high quality, safe, and effective clinical care. We strive for high reliability and aim to create an environment in which risks and issues are anticipated, identified early, and responded to rapidly.

Ramsay Health Care’s slogan “People Caring for People” was developed more than 25 years ago and has become synonymous with Ramsay Health Care and the way we operate our business.  We recognise that we operate in an industry where “care”  is not just a value statement, but a critical part of the way we must go about our daily operations in order to meet the expectations of our customers – our patients.

Patient Safety and Clinical Quality Framework

Waverley Private Hospital operates under Ramsay Health Care’s comprehensive Patient Safety and Clinical Quality Framework which consists of five key areas designed to produce reliable, safe, and effective outcomes:

Click on the interactive framework for more details about each section

Clinical Diagram_INERT S a f e t y S t r u c t u r e C u l t u r e I m p r o v e m e n t P eople

Accreditation

Accreditation is an important driver for safety and quality improvement. All Ramsay facilities undergo formal accreditation processes against the National Standards for Safety and Quality in Health Care. Action plans to address any identified gaps are developed and implemented.

Ramsay facilities engage independent accrediting agencies approved by the Australian Commission on Safety and Quality in Health Care.


Staph Aureus Bacteraemia

At Waverley Private Hospital we aim to minimise the risk of infection to patients, staff and visitors who come to our facility. This hospital has a number of programs in place to detect and prevent infections that are common within health care facilities.

One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands.

Infection Rate (Staph Aureus Bacteraemia)

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Industry Benchmark Rate

 

C. Difficile

Clostridium difficile – is an infection of the bowel that causes diarrhoea and does not cause problems in healthy people. Ramsay Health takes every precaution to prevent these infections from occurring in patients during hospitalization through a well-established infection prevention program.

However, if an individual is unwell, taking antibiotics, taking some cancer medications or medications to supress gastric acid, they may be more likely to contract Clostridium difficile. These infections can be acquired in the community (community acquired) or during your admission (hospital acquired).

The chart shows a breakdown of these infections and where the infection was contracted, as knowing where the infection started can help us prevent the spread to other patients.

Clostridium difficile

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Industry Benchmark Rate

Hand hygiene is conducted in accordance with the ‘five moments’ that is; before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment.

Waverley Private Hospital participates in the national hand hygiene strategy through Hand Hygiene Australia. Hand hygiene audits are conducted three times per year.

Visitors to this hospital are encouraged through appropriate signage to use antiseptic hand rub located throughout the hospital.

Hand Hygiene

Higher score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Industry Benchmark Rate

 

 

The Hand Hygiene brochure has more information on hand hygiene.

The risk of falling increases according to age with data suggesting that one third of people over the age of 65 years have one or more falls a year.

Whilst falls can occur at all ages, the frequency and severity of falls- related injuries increases significantly with age. These injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries may result in hospitalisation or an increased length of stay in hospital.

The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medications and walking in unsafe footwear or slippers.

In 2015 Ramsay increased the focus on falls prevention in hospitals by appointing a National Falls Prevention Advisory Group.  This group has standardized the approach to falls prevention across all Ramsay hospitals by targeting a structured risk assessment, policy and guidelines, equipment for falls prevention and clinical staff education.  Our hospitals use a number of strategies to prevent falls and these include: targeted hourly rounding of patients identified as high risk of falling; ensuring that call bells and personal items are within patient reach; call bells are answered promptly and patients are assisted to the toilet at regular intervals. In addition, Ramsay has purchased low beds, falls mats, and patient alarms to minimise the risk patients falling whilst in our hospitals.

All Patient Falls

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

 

Patient Falls resulting in fracture or head injury

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

 

 

Our Falls Prevention brochure entitled 'Keeping on your Feet' has more information on preventing falls.

Our hospital reviews patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge planning processes.

Unplanned Readmissions within 28 Days

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

Ramsay Health Care doctors undertake surgery in many specialty areas which range from minor procedures to more complex surgery requiring specialised care. We monitor our patient outcomes by comparing any unplanned returns to theatre to other Australian hospitals nationally. The aim is to reduce returns to theatre where possible; however there are many factors which influence these returns and sometimes these returns may save a life.

Unplanned returns to the operating theatre are frequently due to complications, for example to treat bleeding or other problems occurring early after the operation. Some complications following complex surgery are to be expected due to patients’ pre-existing diseases or conditions and the nature of the disease or condition being treated. Our hospitals monitor all returns to theatre and implement any quality measures which may be required so that our patients get the possible outcomes following surgery.

Unplanned Return to Theatre

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors.  Waverley Private Hospital is continually reviewing and implementing a range of medication safety strategies to further improve performance in this area.

The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and Waverley Private Hospital has adopted many of these strategies. This includes the National Inpatient Medication Chart which standardises the documentation on how medicines are prescribed and ordered.  Adoption by Waverley Private Hospital of the User-Applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered.

In addition, Waverley Private Hospital has medication administration policies and processes in place which have been developed using best practice principles.

Waverley Private Hospital takes all medication errors very seriously. We encourage staff to report all errors no matter how minor they may seem. All medication incidents are investigated and actioned. Any serious medication incidents are investigated thoroughly and monitored by the national Clinical Governance Unit.

Medication Safety Errors

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.

Waverley Private Hospital is well equipped with the latest equipment to assist staff to prevent these injuries from occurring. Patients are risk-assessed on admission using an evidenced-based tool.  Staff follow a care plan which is targeted to minimising a patient’s risk of developing a pressure injury for those patients assessed as high risk. This includes inspecting the patient’s skin frequently, managing moisture, keeping the skin dry, optimising nutrition and hydration and moving the patient frequently or using special pressure relieving mattresses when needed.

Patients Developing Pressure Injuries Whilst in Hospital

Lower score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

Our Pressure Injury Prevention brochure has more information on preventing pressure injuries.

As part of your hospital admission, you may require a blood transfusion, which is a procedure where you receive blood through an intravenous cannula in your vein.  Blood transfusions may be necessary for a number of reason for example: if you have a surgical procedure, you are anaemic or if your body is not producing sufficient blood cells.  Blood transfusions can be a lifesaving measure, but is not without some risk and therefore are only prescribed after a doctor has deemed it necessary.  Sometimes an adverse reaction to blood transfusion can occur and is treated immediately. Blood transfusion administration and management are governed by the Australian Commission on Safety and Quality in Health Care Standard for Blood and Blood products.

Blood Transfusion with no reaction

Higher score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

For all babies delivered at our Ramsay maternity facilities an Apgar score is completed for each infant at one minute and again at five minutes after birth. The Apgar score is a simple assessment of how a baby is at birth, which helps determine whether the newborn is ready to meet the world without the need for additional medical assistance. It is determined by five characteristics of the baby – heart rate, breathing effort, muscle tone, reflex irritability and skin colour. Each characteristic is rated from zero to two and the sum of these five characteristic is the total Apgar score of the baby. The rating scale is from 1 –10 with 7 and above being considered normal and the baby is in good health. If the Apgar score is < 7 then it is indicating that the baby requires further attention and support from the health professionals present. Ramsay Maternity Hospitals have less babies requiring additional support in comparison to other maternity hospitals, this means we have healthy babies at birth.

Babies born with a Healthy APGAR Score

Higher score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

 

Waverley Private Hospital focuses on listening and responding to the needs of our patients. Your feedback allows us to continually evaluate and improve on all aspects of our performance.

We encourage feedback from our patients via our website; or via our patient satisfaction surveys.  It is advisable that you express your concerns before you leave the hospital so we can fix any problems for you. The nurse in charge of your ward is a good start but if you remain concerned please ask to speak to a Director or Assistant Director of Nursing/Clinical Services.

Alternatively, there are a number of other ways that you can voice a concern. Our website contains a link to the Private Patients Hospital Charter and this suggests a number of ways for you to express your concerns.

Patient Satisfaction

Higher score is better

 
Hospital Colour Waverley Private Hospital
Industry Standard Colour Average Industry Rate

Net Promoter Score

Ramsay Health Care is committed to providing excellent care and encourages patients to be proactive partners in this endeavour.

For this reason we conduct Net Promoter Score surveys among our patients to understand how well we are meeting expectations, and to identify any areas needing improvement. These surveys are independently conducted by a third party through our private medical surgical facilities in Australia and the results are published quarterly.

Please note: the presence of an asterisk (*) beside the Net Promoter Score indicates less than 25 surveys were returned during the reporting period, which reduces statistical relevance.

Our Net Promoter Score:

62
NPS Score

What does the survey ask?

Patients are asked:

Based on your recent experience, how likely are you to recommend us to your friends and family?

Depending on the rating (from 0 to 10), patients are asked to provide more information to explain their experience.

Calculating the Net Promoter Score

Respondents are grouped into three categories:

  • Promoters: a score of 9 to 10
  • Passive: a score of 7 or 8
  • Detractors: a score of 0 to 6

The Net Promoter Score is calculated by subtracting the percentage of Detractors from the percentage of Promoters. The final score can range from -100 (if every patient is a Detractor) to 100 (if every patient is a Promoter)

Initiatives to improve your care

Cardiac Care

The Ramsay Rule

An initiative that allows patients, their relatives, or carers, to call for rapid assistance when they believe something is ‘not right’ with the clinical condition of the patient.

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Cardiac Care

Speak Up for Patient Safety

An evidence-based framework which escalates awareness of patient safety and encourages staff to challenge potentially risky behaviour.

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