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MyHealthscope - Accreditation, Quality & Safety

Measures of Hospital Performance

At Healthscope, we take quality and safety seriously. To help patients make informed decisions, Healthscope publishes indicators which reflect the quality and safety of its network of 46 hospitals.

Healthscope is proud to be the first private hospital group in Australia to publish the results of its clinical performance and health outcomes on its website. 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 Healthscope, 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.

Click on the links below to view Healthscope data averaged across our 46 hospitals.

ll Healthscope hospitals are 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 three 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 Healthscope Hospitals for the most recent accreditation surveys conducted.

This chart shows that Healthscope Hospitals achieve a higher proportion of Met with Merit ratings compared to other Australian Healthcare Organisations.To view data for each Healthscope Hospital, see Our Hospitals.


The Healthscope corporate office is also accredited by ACHS using the National Safety and Quality Health Service Standards - Corporate Program.

This accreditation looks at how well we run our 46 hospitals, and measures the entire organisation against criteria such as risk management, occupational health and safety, human resources, quality improvement, IT service delivery and consumer involvement.

The graph shows that the corporate office achieved a very high proportion of MM ratings at the most recent accreditation survey in March 2015.

Other awards

Healthscope is proud of the recognitions of excellence bestowed on its hospitals and staff. Examples of recent awards are:

  • Lynette Hernandez – The Sydney Clinic (NSW) was named in the ‘Nurse of the Year’ category at the 2016 HESTA Australian Nursing Awards.
  • Emma Piggott - Allamanda Private Hospital (QLD) won the 2015 Star Award for Teamwork and Integrity.
  • Stephen Carr – Campbelltown Private Hospital (NSW) was a 2015 Bupa Patient Choice Awards finalist.
  • Flinders Private Hospital (SA) won the 2015 Star Award for Responsibility.
  • Glenda Howard – Hobart Private Hospital (TAS) was awarded 2nd Place in the 2015 Star Awards for Responsibility.
  • Tony Rosendale – Hobart Private Hospital (TAS) was a 2015 Bupa Patient Choice Awards finalist.
  • John Fawkner Private Hospital (VIC) won the 2015 Healthscope Achievement Award for Best Accreditation Performance.
  • Anne Graham - John Fawkner Private Hospital (VIC) was awarded the Inaugural National Award for Excellence in Management of Blood and Blood Products at the Brisbane National Blood Symposium.
  • Anne Graham – John Fawkner Private (VIC) was awarded 2nd Place in the 2015 Star Awards for Service Excellence.
  • The Quality & Consumer Consultants from John Fawkner Private Hospital (VIC) were awarded 2nd Place in the 2015 Star Awards for Aspiration.
  • The Concierge Team from Knox Private Hospital (VIC) was awarded 2nd Place in the 2015 Star Awards for Service Excellence.
  • Deane Presdee – Lady Davidson Private Hospital (VIC) was awarded the 2015 Star Award for Responsibility.
  • Karyn Caldow – Memorial Private (SA) was a 2015 Bupa Patient Choice Award finalist.
  • Ross McAliece – Mount Private Hospital (WA) won the 2015 Star Award for Aspiration.
  • Kate Stafford – National Capital Private Hospital (ACT) won the 2015 Bupa Patient Choice Award.
  • Kate Stafford – National Capital Private Hospital (ACT) was awarded the 2015 Star Award for Service Excellence. This was for the introduction of Cardiac Surgical Services.
  • Jedda Tomkins – Northpark Private Hospital (VIC) received an honourable mention in the 2015 Star Awards
  • Timothy Whicker – The Sydney Clinic (NSW) was awarded 2nd Place in the 2015 Star Awards for Aspiration.

Safety and Quality Improvement Programs

Healthscope Hospitals have a wide range of programs and protocols, which focus on the continuous enhancement of safety and optimal health care for all patients, visitors and employees.

Ten Tips for Safer Healthcare

Consistent with the Australian Commission on Safety and Quality in Health Care (ACSQHC), Healthscope recognises the potential for enhanced safety by engaging our patients in a safety partnership.

The Commission has produced a fact sheet designed to assist patients in hospital to become more actively involved in their own health care. It explains how things can go wrong and provides tips for improving patients’ health care. It provides an outline of the kind of information that can reasonably be expected from the patient’s health care professional, how to find out more about the patient’s condition, how to manage medication and what to do if patients have concerns about their health care.

For further details on this health care fact sheet, see: 10 Tips for Safer Healthcare

WHO Surgical Safety Checklist and Timeout Process

At Healthscope Hospitals where surgery and procedures are performed, we follow the Royal Australian College of Surgeons’ Implementation Guidelines for ensuring correct patient, correct side and correct site surgery as well as the WHO Guidelines for Safe Surgery 2009 .

The protocol involves the use of a Surgical Safety Checklist and a surgical team Time Out for patient verification, confirmation of the procedure, the procedure side and site, patient allergy status and other key elements of a safe surgery.

Venous Thromboembolism (VTE) Prevention

VTE is a blood clot in the veins or lungs that can be a complication of hospital treatment. Healthscope hospitals use the guidelines published in the 'Prevention of Venous Thromboembolism: Best Practice Guidelines for Australia and New Zealand 5th Edition October 2010'.

The guidelines recommend treatment for patients at risk of VTE. The extent of treatment is dependent on the patient’s clinical risk factors. VTE prophylaxis (preventative measures) occur in consultation with the patient’s doctor and may include:

  • Mechanical graduated compression stockings (GCS) or intermittent pneumatic compression (IPC) devices including foot pumps.
  • Pharmacological prophylaxis (drugs to reduce the risk of VTE), for example, low dose unfractionated heparin (UFH) or low molecular weight heparin (LMWH)

National Inpatient Medication Chart

The National Inpatient Medication Chart (NIMC) is a major initiative of The Australian Commission on Safety and Quality in Health Care (ACSQHC).

The NIMC is designed to improve the safe use of medicines through the standardisation of medication ordering in hospitals, with a common medication chart in use at all public and private hospitals in Australia.

In its summary rationale for a national medication chart”, The ACSQHC explains that ensuring a hospital patient receives the best therapy in a safe, accurate manner is a complex process involving many health professionals including doctors, pharmacists and nurses. A critical element of this process is the communication of the prescription.

Evidence suggests this communication can be made safer if the process is standardised and made with a better understanding of safety principles.

For example if a nurse or doctor works in both a public and a private hospital, the medication charts used in both settings will be very similar.

The clinicians’ familiarity with the layout of the medication chart helps to reduce inadvertent errors.

The use of the National Inpatient Medication Chart has proven to reduce the risk of medication errors. Twenty Healthscope hospitals are participating in an audit of the National Inpatient Medication Chart run by the Australian Commission on Safety & Quality in Healthcare. This will help to ensure that the chart is being used correctly and safely for every patient.

Obstetric Care

All hospitals that have obstetric care dial into a regular teleconference to discuss improvements and best practice.

A specialised e-learning training package has been introduced to ensure that nursing staff are up to date with the latest practice in areas such as Electronic Foetal Monitoring, Shoulder Dystocia, Newborn Care and Post Partum Haemorrhage.

Blood Transfusion

Our hospitals have policies and procedures in place to make sure blood transfusions are managed smoothly. Our policies are referenced to the latest guidelines and documents from the National Blood Authority (NBA), National Health & Medical Research Council (NHMRC) and Australasian Society of Blood Transfusion (ASBT). Nursing staff involved in blood transfusions have completed an e-learning “Bloodsafe” training package. We regularly liaise with the Australian Red Cross Blood Service to ensure that our practices are consistent and comply with all requirements. The National Transfusion Committee addresses any issues arising and ensures that hospitals and pathology services work well together.

Patient Centred Care

All hospitals conduct patient surveys each quarter and results of these are compared from site to site to make sure any issues are addressed.

Healthscope has trialed a new project in six of our hospitals during 2010/11 that has involved specific customer service and patient-centred care education programs for nursing staff, and introduction of patient-centred care strategies (such as bedside handover).

The patients were then surveyed again to find out about their experience in hospital.

The project has shown good results and is currently being rolled out to all hospitals.

X-ray and Diagnostic Imaging

Healthscope have achieved Diagnostic Imaging accreditation (2nd stage) for 34 hospital-based and four stand-alone diagnostic imaging services. All services are currently accredited until 2015 and we were the first major hospital group to achieve the second stage accreditation.

Patient mental health is measured on admission to Healthscope mental health facilities and again on discharge so that we can measure the improvement made. Patients 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 Healthscope mental health facilites. The dark coloured bar shows mental health problems on admission and the pale coloured bar shows that these problems have decreased on discharge. Healthscope mental health facilities achieve 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 Healthscope mental health facilites achieve self-assessed improvement similar to 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.

To view data for each Healthscope Hospital, see Our Hospitals.

Patient abilities, mobility and independence are measured on admission to our hospitals and again on discharge so that we can measure the improvement made.

Patients demonstrate improvement in their abilities, mobility and independence after treatment at Healthscope Hospitals.

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.

For example if a hospital has a high number of patients over the age of 75 years, compared with other hospitals, the patient abilities may not improve so much.

Orthopaedic Fracture Rehabilitation

This graph shows the average improvement in patients at Healthscope Hospitals 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. Rehabilitation patients at Healthscope Hospitals achieve outcomes similar to those of patients in other Australian hospitals.

Rehabilitation for Hip, Knee or Shoulder Replacement


This graph shows the average improvement in patients at Healthscope Hospitals following rehabilitation after a hip, knee or shoulder replacement. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Rehabilitation patients at Healthscope Hospitals achieve outcomes similar to those of patients in other Australian hospitals.

Stroke Rehabilitation


This graph shows the average improvement in patients after stroke rehabilitation at Healthscope Hospitals. The dark coloured bar shows patient abilities on admission and the pale coloured bar shows that these abilities have improved on discharge. Rehabilitation patients at Healthscope Hospitals achieve outcomes similar to those of patients in other Australian hospitals.

To view data for each Healthscope hospital, see Our Hospitals.

Rehabilitation for Other Neurological Conditions

This graph shows the average improvement in patients at Healthscope Rehabilitation facilites 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 Healthscope hospital achieve outcomes better than those of patients in other Australian hospitals.

What we are doing to continually improve our patients’ rehabilitation

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

  • 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.

All Healthscope Hospitals have 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 are Healthscope Hospitals doing to prevent infections?

Specialised Infection Control teams 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 Healthscope Hospitals. 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 infection caused when this bacteria enters the blood stream.


This graph shows the number of Staphylococcus aureus infections in Healthscope Hospitals 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 two cases per 10,000 patient days.

Patients in Healthscope Hospitals on average have a very low number of infections.


This graph shows the number of Clostridium Difficile infections in Healthscope Hospitals compared with the rate typical in other hospitals in Australia.

Rates of infection typically vary from state to state. The rate varies from two to three 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 in Healthscope Hospitals on average have a very low number of infections.

Not all patients contract clostridium difficile in hospital - some patients are admitted already having this condition. The chart above shows all cases of cdiff identified in hospital, both community and hospital-acquired. The chart below shows whether or not the patient was admitted already having this condition. Hospitals need to identify both types of patients in order to have the best chance of preventing Cdiff from spreading to other patients.

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

To view data for each Healthscope hospital, see Our Hospitals.

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 Nursein 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 Healthscope, 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

and 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 Healthscope Hospitals 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 Healthscope 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. Healthscope Hospitals use a gold-standard auditor, 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 Healthscope Hospitals 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 in Healthscope Hospitals compared with the Australian benchmark of 70%.

Staff at Healthscope Hospitals on average have a high rate of compliance with hand hygiene. 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 in Healthscope Hospitals (nationally) 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 first graph on the left (below) shows which groups were audited. The graph on the right shows the hang hygiene rate for different staff within our hospitals.



This graph shows that doctor hand hygiene rates have improved since we introduced public reporting on this website in 2016.

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.

The following strategies are typically 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?

In Healthscope Hospitals, 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:

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 Healthscope Hospitals 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 Healthscope Hospitals for the past six years, compared with the industry rate.

Falls are presented as a percentage of patient days – allowing us to compare Healthscope Hospitals with other hospitals of a different size. Patients in Healthscope Hospitals on average have a lower rate of falls than those in other hospitals.

*In January 2015, an external audit found an inconsistency in hospital data for 2013. As a result, the chart has been revised and the rate has increased.

See details on: How we work out our falls rate

For a discussion on the data, see: Limitations of data

To view data for each Healthscope hospital, see Our Hospitals.

What we are doing to further reduce falls

Reducing the risk of patient harm resulting from falls is one of the patient safety goals of the Australian Commission on Safety & Quality in Healthcare (ACSQHC).

Healthscope has a falls-reduction program that provides guidelines for everyone involved in the care of patients in all of our hospitals.

The falls-reduction program includes patient evaluation, interventions, staff education and training, patient education and outcomes assessment.

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

  • 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 Healthscope, 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.

Brochures

Video

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 Healthscope Hospitals 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
  • Are older
  • Taking certain medications or
  • Have chronic illnesses such as diabetes or anaemia.

Our hospitals have 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 in Healthscope Hospitals that have developed a pressure injury during their admission to hospital. The rate for the past two 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 in Healthscope Hospitals are less likely to develop a pressure injury compared with other Australian hospitals.

Although the overall number of pressure injuries has risen, it is important to identify pressure injuries at an early stage. Identifying more stage 1 pressure injuries (with redness and unbroken skin) can often be a good thing, as it allows hospitals to put strategies in place to prevent the injuries from getting any worse.

Sometimes, despite our best efforts, a patient does develop a pressure injury - however we aim to minimise this number.

To view data for each Healthscope hospital, see Our Hospitals.

What we are doing to reduce pressure injuries

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

  • A risk assessment is performed to identify patient that are vulnerable to pressure injuries.
  • Patients identified as ‘high risk’ are referred to the dietitian for nutritional assessment and advice.
  • Pressure relieving devices are used. These include specialised mattresses, cushions, wedges, sheepskins, water-filled supports, contoured or textured foam supports, heel elevators, gel-filled supports and bead filled supports.
  • Preventing exposure to excessive moisture or dryness.
  • Positioning: Regularly changing the position of the patient and encouraging walking or movement if possible.
  • Individual reporting: Examining each case of pressure injuries to determine why it occurred and how to prevent this happening again.
  • Education for nursing staff in pressure injury identification, prevention and management.
  • Patient education provided on pressure injury prevention at pre admission and or admission.
  • Referral to a wound management consultant in the event of a pressure injury developing or if admitted with a pressure injury.

A blood transfusion is a procedure where you receive blood through an intravenous cannula (IV) inserted into a vein.

You may need a blood transfusion if your body cannot make parts of your own blood, if your blood cells are not working properly, or if you have lost blood.

Blood contains red cells which are essential for carrying oxygen around the body. A blood transfusion may be given because of a shortage of red blood cells in the blood (anaemia), either because the body is not making enough of them, or because of blood loss.

Sometimes the bone marrow, which produces blood cells, doesn’t work properly. The bone marrow can be affected by chemotherapy or diseases.

In some cases anaemia can be treated with medicines but in other cases, a blood transfusion may be the best treatment.

Most people can cope with losing a moderate amount of blood without needing a blood transfusion, as this loss can be replaced with other fluids. However, if larger amounts of blood are lost, a blood transfusion could be the best way of replacing blood rapidly.

A blood transfusion may be needed to treat severe bleeding, for example during or after an operation, childbirth or after a serious accident. There are are many useful resources for patients about blood transfusion available.

Transfusion does not just refer to blood – often other blood products are used. These include:

  • Fresh blood components, such as red blood cells, platelets, fresh frozen plasma or cryoprecipitate.
  • Plasma-derivatives such as albumin, immunoglobulins and clotting factors.

A blood transfusion can be lifesaving or significantly improve quality of life. Australia has one of the safest blood supplies in the world, however, as with all medical procedures, a blood transfusion is not completely free from risk.

It is very important that all patients receive blood and blood product transfusions appropriately and safely. Blood transfusions are given to patients only where the doctor has assessed it as absolutely necessary.

Patients must give consent for a blood transfusion. Consent should be documented on a consent form or by documenting the discussed information in your medical record.

It is very important that transfusions are carried out by trained professional staff, using the techniques outlined in the National Safety and Quality Health Service Standards. This is double checked and audited on a regular basis in our hospital.

One way that we monitor the success of blood transfusions is by keeping track of any adverse reactions – both major and minor. Adverse reactions are rare, but can include:

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

At Healthscope Hospitals we document and investigate every case and take action to reduce the number of adverse transfusion events that occur.

Healthscope Hospitals have many strategies in place to prevent adverse transfusion events from occurring.

This graph shows the number of patients at Healthscope Hospitals that had a transfusion with no significant adverse event. The rate for the past six years is shown in the coloured bars. This is compared to the rate of transfusion events in other Australian hospitals (the grey bar). The graph shows that patients at Healthscope Hospitals are less likely to have an adverse transfusion event, compared with other Australian hospitals.

*In January 2015, an external audit found an inconsistency in hospital data for 2013. As a result, the chart has been revised and the rate has increased.

What we are doing to reduce the risk of adverse transfusion events

The following strategies are used:

  • National policies and procedures, consistent with national evidence based guidelines for pre-transfusion practices, prescribing and administration of blood.
  • Avoiding unnecessary blood transfusions by use of alternative medications, treatments 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.
  • Education and competency training for nursing staff in blood transfusion administration.
  • Patient education and provision of written materials explaining blood transfusions.
  • Individual reporting: Examining each adverse transfusion event to determine why it occurred and how to prevent this happening again.
  • Careful monitoring of patients and taking close observations during administration of a blood transfusion.
  • Working closely with the pathology laboratory that provides the blood.
  • Monitoring and auditing compliance to transfusion policies and procedures.
  • There is a robust system for reporting and feedback for adverse events, incidents and near misses relating to transfusion practice.
  • Transfusions are not conducted at every Healthscope Hospital. If a hospital does not have sufficient experience in conducting a transfusion, the patient is moved to another hospital for this procedure.
  • Healthscope has a National Transfusion Governance Committee that oversees best practice standards for transfusion management in all hospitals – and also reviews adverse events nationally so that all hospital can learn from them.

When a patient visits an Emergency Department, anywhere in Australia or New Zealand, the triage nurse carries out an assessment of how urgent the patient’s condition is. Each patient is assigned a triage category from 1 to 5 on the Australasian Triage Scale.

According to the best practice guidelines, patients must be seen for medical assessment and treatment within the following times:

  • Category 1 patients must be attended to immediately (e.g., cardiac arrest)
  • Category 2 patients attended to within 10 minutes (e.g., severe blood loss)
  • Category 3 patients attended to within 30 minutes (e.g., head injury but conscious)
  • Category 4 patients attended to within 60 minutes (e.g., sprained ankle, possible fracture)
  • Category 5 patients attended to within 120 minutes (e.g., cut not requiring stitches)

Patients that are category 1, 2 or 3 will be seen before category 4 and 5, even if they arrive in the department at a later time. If you visit an Emergency Department you can ask the triage nurse what category you have been assigned and this may give you an idea of how long you may be expected to wait.

All hospitals with Emergency Departments measure how quickly patients are seen in the Emergency Department. The graphs below show the percentage of patients in each category that are seen within the recommended time at Healthscope Hospitals.

On average, patients visiting Emergency Departments at Healthscope Hospitals are seen more quickly than in other Australian hospitals.

To see the emergency waiting times for Healthscope Hospitals:







To view data for each Healthscope Hospital, see Our Hospitals.

What we are doing to improve our emergency response times

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

  • Continually reviewing our doctor and nurse staffing levels.
  • Monitoring the number of ambulance presentations to our Emergency Departments.
  • Monitoring bed availability for transfers to the ward.

Many patients who come to Healthscope Hospitals have an operation in our theatres. Most operations require some kind of anaesthetic, administered by an Anaesthetist.

After waking up from an anaesthetic, patients require close monitoring to make sure that their pain and conscious state, and observations such as blood pressure are all back to normal. This typically happens in the Recovery Unit.

After a large operation, such as a heart bypass operation, an admission to the Intensive Care Unit may be planned, to allow close monitoring by specialised equipment. On rare occasions, other patients may have an unexpected reaction to an anaesthetic, and may require an unplanned admission to the Intensive Care Unit for monitoring.

Tracking the number of patients who have an admission to Intensive Care after an operation is one way that we can judge the quality of hospital care. Good nursing care can help reduce the rate of unplanned admission to Intensive Care and good monitoring can pick up any problems early.

This graph shows the percentage of patients admitted to Healthscope hospitals that have required an unplanned admission to the Intensive Care Unit within 24 hours of their operation. The rate for the past three years is shown in the green bars. This is compared to the rate of “unplanned admission to Intensive Care” in other Australian hospitals (the grey bar).

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

To view data for each Healthscope hospital see: Our Hospitals.

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

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

  • We review each admission to Intensive Care to check if there were any preventable factors.
  • Before operations, the nurses, doctors and anaesthetists carefully check each patient’s risks for anaesthetic.
  • The Theatre and Recovery Units use a consistent process for discharging patients either to the ward or to home, to make sure they have fully recovered from the anaesthetic.
  • If a patient has additional risk factors, sometimes an Intensive Care bed is planned and booked in advance, to make sure the post-operation monitoring is the best possible.
  • We monitor this data to make sure that the rate of unplanned admission to Intensive Care is not increasing.

For many operations and procedures (such as arthroscopy, colonoscopy) that are performed in Healthscope Hospitals, an overnight stay is not required.

Patients are admitted a few hours before their operation or procedure, and go home on the same day, after they have recovered from their anaesthetic.

After waking up from an anaesthetic, patients require close monitoring to make sure that their pain and conscious state, and observations such as blood pressure are all back to normal.

This typically happens in the Recovery Unit. On rare occasions, patients may have an unexpected reaction to an anaesthetic or procedure, and may require an unplanned overnight stay in hospital, or transfer to another hospital.

Tracking the number of day patients who have an unplanned overnight stay after an operation is one way that we can judge the quality of hospital care. Good planning and medical care can help reduce the rate of unplanned overnight admissions.

This graph shows the percentage of day patients admitted to Healthscope hospitals that have required an unplanned overnight stay or transfer to another hospital. The rate for the past three years is shown in the purple bars. This is compared to the rate of “unplanned admission to Intensive Care” in other Australian hospitals (the grey bar).

The graph shows that patients admitted to Healthscope hospitals are less likely to have an unplanned overnight stay or transfer to another hospital compared to other Australian hospitals.

To view data for each Healthscope hospital see: Our Hospitals.

What we’re doing to further reduce unplanned overnight admission

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

  • We review each unplanned transfer or overnight admission to check if there were any preventable factors.
  • Before operations, the nurses, doctors and anaesthetists carefully check each patient’s risks for the operation and recovery.
  • Pre-admission clinics are used to make sure the patient and staff are as prepared as possible for the operation or procedure.
  • The Theatre and Recovery Units use a consistent process for discharging patients home, to make sure they have fully recovered from the operation.
  • If a patient has additional risk factors or requires more intensive monitoring, sometimes an overnight ward bed is planned and booked in advance, to make sure the post-operation monitoring is the best possible.
  • We monitor this data to make sure that the rate of unplanned transfer and admission to hospital is not increasing.

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 a 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 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 Healthscope hospitals that have required an unexpected and unplanned readmission to hospital within 28 days of their first admission. The rate for the past six 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 Healthscope hospitals 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.

To view data for each Healthscope hospital, see Our Hospitals.

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 re-admission 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, e.g. with Physiotherapist and General Practitioner.
  • We monitor this data to make sure that the rate of unplanned readmission is not increasing.

Most Healthscope Hospitals have an operating theatre and carry out many sessions of surgery every year.

One of the ways of monitoring the success of surgery is to check whether any patients require an unexpected second operation – we call this return to theatre.

There are many reasons why a patient may need a further operation – however where possible we aim to minimise this number.

This graph shows the percentage of patients having an operation or procedure at Healthscope Hospitals that have required a return to theatre during the same admission.

The rate for the past six years is shown in the blue bars. This is compared to the rate of return to theatre in other Australian hospitals (the grey bar).

The graph shows that patients undergoing surgery in Healthscope Hospitals are less likely to have an unexpected return to theatre compared with other Australian hospitals.

To view data for each Healthscope Hospital, see Our Hospitals.

What we are doing to reduce unplanned returns to theatre

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

  • Careful monitoring of patients in recovery.
  • Ensuring patient’s level of pain is carefully assessed.
  • Reviewing every case when a patient requires a return to theatre, to work out the reasons why and how to prevent it in future.
  • Conducting thorough pre-operative evaluation including coagulation studies and anti-coagulant therapy management where indicated.
  • Pre-admission assessment of high risk patients to make sure all required tests and precautions are taken.

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 the Healthscope 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 Healthscope Hospitals that have required an unplanned admission to the Neonatal Intensive Care Unit.

The rate for the past two 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 Healthscope Hospitals are less likely to have an unplanned admission to the Neonatal Intensive Care compared with other Australian hospitals.

To view data for each Healthscope hospital see: Our 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/midwife assesses the baby's overall condition, including breathing, heart rate, colour, activity and temperature.

A score known as the Apgar score is used to measure this, one minute and five minutes after birth.

The highest Apgar score is 10. The five minute Apgar score is regarded as more important than the one minute score because it is believed to be more reflective of the baby's overall health.

At Healthscope Hospitals we measure the Apgar score for every baby born. This graph shows the percentage of babies born at Healthscope Hospitals that have a healthy Apgar score five minutes after birth.

The rate for the past five years is shown in the yellow bars. This is compared to the rate in other Australian hospitals (the grey bar).

A healthy Apgar score is defined as a score of seven or above.

The graph shows that the percentage of babies born at Healthscope Hospitals with a healthy Apgar score is higher than other Australian hospitals.

*In January 2015, an external audit found an inconsistency in hospital data for 2013. As a result, the chart has been revised and the rate has decreased.

More Information

Each of the five areas are 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 would like you to have the best possible experience. If you have an uncomplicated pregnancy, you will be admitted to hospital just before you give birth.

The number of days you will spend in hospital after having your baby will depend on whether you have a vaginal delivery or a caesarean section. Most patients stay a little longer in hospital after a caesarean section.

It can be reassuring to know how long you will spend in hospital after your baby is born.

The graph below shows the average length of stay in Healthscope Hospitals for childbirth. The length of stay in other Australian public and private hospitals is also shown.

Many patients choose to stay in hospital for as long as possible after the birth, particularly for a first baby, however it important to note that you are free to go home earlier if you choose to do so.

Women having a baby in Healthscope Hospitals and other Australian private hospitals stay longer in hospital than patients in Australian public hospitals.

Some Healthscope Hospitals offer a Little Luxuries package, transferring mum and baby to a local luxury hotel after the birth, once approved by the obstetrician and paediatrician. There is a midwife on site 24 hours, 7 days a week for assistance.

To view data for each Healthscope hospital, see Our Hospitals.

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.

If you would like more information about the pros and cons of public reporting, see: Public Reporting Literature

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