Mount Hospital

Mount Hospital is fully accredited against the National Safety and Quality Health Service Standards (NSQHSS), 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. This occurs every three years, in accordance with the Australian Commission on Safety and Quality in Health Care.

The hospital is measured against eight overarching standards with many different criteria, including patient-centred care, medication management, clinical handover, infection prevention and staff education. Each item receives a rating, and recommendations for improvements may be made.

At the most recent survey in July 2021, Mount Hospital passed all 147 applicable criteria and achieved full accreditation. Two recommendations were received. The hospital's accreditation report can be viewed here.

At Mount Hospital, we are committed to providing patients with the best possible experience during their hospital stay. Patient experience often reflects the personal side of care. To evaluate how well we meet patient needs, we invite our patients to complete a survey after discharge. We have based our survey on the Australian Hospital Patient Experience Question Set (AHPEQS) developed by the Australian Commission on Safety and Quality in Health Care for use in both public and private health services.

Completion of our survey is voluntary and anonymous. Most patients fill in their surveys online. We conduct surveys continually throughout the year, which provides us with feedback that is more accurate than periodic surveys. Sample size has been building as we focus on electronic rather than paper survey formats.

Our senior hospital staff have access to Mount Hospital's survey results via an electronic Patient Experience Portal. This allows them to review feedback immediately and identify any opportunities for improvement. Maintaining anonymity, both positive and negative patient comments are shared with relevant staff. This is part of our commitment to provide the best possible experience for our patients.

Mount Hospital's survey results are also monitored by the Quality Department at Healthscope Corporate Office. Reports are presented to senior management and the Board.

One of our key questions is about the overall quality of treatment and care, which can be rated on a scale of 1 to 5, from 'very poor' to 'very good'. The graph below shows patients' responses during 2023.

This graph shows that the majority of our patients have rated their overall treatment and care at Mount Hospital as 'very good.'

he graph below shows the percentage of patients who have rated their overall treatment and care as 'very good' or 'good' since we first included this question in the survey.

This graph shows that combined 'very good' and 'good' ratings have been consistently above 90%. [Data correct as at 14 March 2024]

Net Promoter Score

Another key question we as or patients is “How likely is it that you would recommend Mount Hospital to a family member, friend or colleague?” Patients can rate their response on a scale of 0 (Not at all likely) to 10 (Extremely likely). This allows us to calculate the Net Promoter Score (NPS), which is an index from -100 to +100.

The graph below shows the Net Promoter Score for Mount Hospital during 2023. The higher the score, the more patients would recommend the hospital. Scores above 50 are considered ‘excellent’.

This graph shows that the NPS at Mount Hospital during 2023 was 68.5.

What are we doing to improve patient experience?

Mount Hospital employs a variety of strategies to improve patient experience. These include:

• inviting feedback from all patients, listening to their views and making changes as a result
• ongoing staff education and provision of resources to ensure that care is person-focused and of the highest standard
• hospital management constantly monitoring the rating of overall treatment and care and taking action to address any areas of concern
• consulting with Healthscope's National Patient Experience Manager to assist us in implementing strategies to enhance patient experience
• engaging Consumer Consultants who provide feedback from a patient's or carer's perspective
• involving patients in their care, for example by shift handover occurring at the bedside
• follow-up phone calls to patients after discharge from hospital to ensure they are recovering well and are given an opportunity to provide feedback
• keeping relatives informed of the current location of their family member in hospital via the 'Patient Finder' app
• 'Patient Journeys' - volunteer patients diarising detailed feedback on every part of their hospital experience from pre-admission to post-discharge follow-up
• focused initiatives to address areas of concern, such as taste testing to improve our menu, or measuring of noise levels within different hospital areas

At Mount Hospital, we measure the ability, mobility and independence of patients on admission and again on discharge, to assess their level of improvement. We use the internationally recognised FIM (Functional Independence Measure), a scale which measures the success of rehabilitation.

It is important to note that rehabilitation outcomes are not solely dependent on the quality of care provided. Patient-specific factors such as age, severity of condition and presence of other health issues can influence how much improvement is achieved.

These figures show that patients at Mount Hospital are of a similar age to patients in other Australian hospitals. The chart below shows he percentage of patients with a severe impairment on admission. The coloured bars represent Mount Hospital's rate. This is compared to the rate in other Australian hospitals, shown in the grey bar.

This chart shows that more patients at Mount Hospital have severe impairments on admission than in other Australian hospitals.

See a definition for severity here.

The graph below shows the improvement in patients after rehabilitation for a joint replacement. The dark coloured bars represent patients' abilities on admission to Mount Hospital. The pale coloured bars represent patients' abilities on discharge. This is compared to the outcomes at other Australian hospitals, shown in the grey bars.

This graph shows that rehabilitation patients with a joint replacement at Mount Hospital have achieved similar outcomes as patients in other Australian hospitals.

What are we doing to improve rehabilitation outcomes?

Mount Hospital employs a variety of strategies to improve patients' rehabilitation outcomes. These include:

• a multi-disciplinary team approach, including expert nursing and allied health professionals
• individual and group therapy, often including practice of tasks of daily living
• use of Functional Electrical Stimulation (FES) to improve strength and function in stroke patients
• depression screening for all stroke patients to support full participation in rehabilitation
• swallowing and/or speech/language therapy with a Speech Pathologist

Mount Hospital follows strict infection control procedures, and staff take every precaution to prevent infections. Specialised infection control staff collect and analyse data on infections in order to identify and implement best practices to reduce infection rates.

Patients with weakened immune systems, wounds or invasive devices such as drips are at greater risk of infection than the general public.

One of the infections that we closely monitor at Mount Hospital is Staphylococcus Aureus Bacteraemia, also known as SAB or 'Golden Staph.' SAB can cause skin infections, blood poisoning, pneumonia and other infections.

The graph below shows the number of Staphylococcus Aureus infections. The coloured bars represent Mount Hospital's rate. This is compared to the Australian government target shown in the grey bar. The national benchmark for SAB is no more than 2 cases per 10,000 days of patient care.

This graph shows that in recent years the rate of SAB infections at Mount Hospital was slightly higher than the Australian government target.

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

Methicillin is an antibiotic commonly used to treat Staph infections. Most cases of SAB respond to methicillin. These are known as MSSA, or methicillin-sensitive Staphylococcus Aureus. However, some cases of SAB are resistant and therefore more difficult to treat. These are called MRSA, or methicillin-resistant Staphylococcus Aureus.

We started reporting MSSA and MRSA rates separately in 2018. The graph below shows the number of MSSA and MRSA infections. The coloured bars represent the rate at Mount Hospital. This is compared to the rate in Australian public hospitals, as shown in the grey bars.

This graph shows that during the last reporting period, the rate of MSSA infections at Mount Hospital was above the rate in Australian public hospitals. There were no MRSA infections during this period.

What are we doing to prevent infection?

Mount Hospital employs a variety of strategies to prevent infections. These include:

• auditing how often and how well staff wash their hands using soap and water or hand sanitiser
• using gloves and specialised sterile equipment
• assigning a dedicated Infection Control Nurse responsible for educating staff and implementing infection control strategies
• using specialised disinfectants when cleaning facilities
• following national guidelines for high level disinfection and sterilisation processes
• placing hand sanitiser dispensers in public areas throughout our hospital so that they are readily accessible to staff, patients and visitors

What can you do to help?

At Mount Hospital, patients and visitors are part of the health care team. There are a number of things you can do to reduce the risk of infection for yourself and others:

• Wash your hands carefully with soap and water or use hand sanitiser upon entering and leaving the hospital. This is the most important way in which you can prevent the spread of infection.
• Cover your mouth and nose with a tissue when you cough or sneeze. Clean your hands afterwards - every time!
• If you do not have a tissue available, cough or sneeze into your elbow, not into your hand.
• As a patient, report any infection you have had, especially if you are still on antibiotics.
• Make sure you take the full course of antibiotics you have been given, even if you are feeling better
• If you have a dressing for a wound, keep the skin around the dressing clean and dry. Let the healthcare worker looking after you know promptly if it becomes loose or wet.
• Tell your healthcare worker if the area around any drips, tubes or drains inserted into your body becomes red, swollen or painful.
• Let the healthcare worker looking after you know if your room or equipment hasn't been cleaned properly
• Stop smoking before any surgery or procedure, as smoking increases the risk of infection.

Visitors

• Please do not visit if you have an illness such as a cough, cold or gastroenteritis ('gastro') or are feeling generally unwell.
• 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 Brochure
• Watch: Interactive Video Training

Hand Hygiene is another name for hand washing or cleaning. Good hand hygiene is an important part of infection control. Germs can survive on unwashed hands for over an hour, and we can unknowingly transmit bacteria and viruses to others.

All Healthscope staff are required to frequently wash their hands with soap and water or with waterless hand sanitiser. Both are equally effective. We follow the World Health Organization's guidelines for hand hygiene, which specify the following times when health care staff must wash their hands:

• before touching a patient
• after touching a patient
• before a procedure
• after a procedure
• after touching a patient's belongings or surroundings

At Mount Hospital, we use auditors who are accredited by Hand Hygiene Australia to record whether or not hand hygiene has been performed correctly.

The graph below shows the levels of hand hygiene compliance. The coloured bars represent Mount Hospital's rate. This is compared to the Australian national benchmark of 80%, shown in the grey bar.

When audits are performed, each professional group is checked - including doctors, nurses, cleaners and other hospital staff.

The first graph below on the left shows which groups were audited. The graph on the right shows the hand hygiene compliance rate for different staff within the hospital. It shows that the compliance rate for nurses has been higher than for other groups.

The graph below shows doctor hand hygiene rates since 2018.

What are we doing to improve hand hygiene compliance?

Mount Hospital employs a variety of strategies to improve hand hygiene compliance. These include:

• ongoing education programs for staff about infections and hand hygiene
• a designated Infection Control Nurse responsible for educating staff and implementing infection control strategies
• placement of hand sanitiser dispensers in convenient areas throughout the hospital, including hallways and patient rooms
• use of specially designed washbasins where water can be turned on and off without touching the tap

What can you do to help?

At Mount Hospital, patients and visitors are part of the health care team. Good hand hygiene is the most important way in which patients and visitors can prevent the spread of infection in hospital. There are a number of things you can do:

• 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 Brochure
• Watch: Interactive Video Training

Falls are a leading cause of hospital-acquired injury and frequently prolong or complicate hospital stays. Patients may experience a fall because they are weakened by a medical condition or after an accident or injury.

The graph below shows the percentage of patients who have had a fall. The coloured bars represent Mount Hospital's rate. This is compared to the rate of falls at other Australian hospitals, shown in the grey bar.

This graph shows that in recent years, patients at Mount Hospital have had a lower rate of falls than patients in other Australian hospitals.

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

What are we doing to prevent patient falls?

Mount Hospital employs a variety of strategies to reduce the risk of patients having a fall. These include:

• risk assessments to identify patients at risk of falling
• ongoing staff education on falls prevention
• patient education on prevention of falls in hospital and at home
• use of safety equipment such as lifting hoists, walking aids and chair or bed sensors that alert staff when a patient at risk of falling gets up unassisted
• review of each fall to assess if there were any preventable factors

What can you do to help?

At Mount Hospital, patients and visitors are part of the health care team. You may like to print a brochure containing handy hints about preventing falls. You can also watch a helpful video.

Brochure: Don't Fall For It

Video: Speak Up Reduce Your Risk of Falling

Safe medication management is important to us at Mount Hospital. There are many systems in use throughout the hospital to support and promote safety for supplying and administering medications, as well as monitoring their effects.

Staff at Mount Hospital follow strict guidelines to ensure that all medications are administered safely and correctly. We adhere to the 7 Rights of Medication Administration:

• The Right Person
• The Right Documentation and clinical context
• The Right Drug
• The Right Dose
• The Right Date/Time
• The Right Route
• The Right to Uninterrupted Medication Administration

Errors in medication administration are captured in the hospital’s incident reporting system and investigated.

The graph below shows the rate of medication errors which required intervention. The coloured bars represent the rate at Mount Hospital. This is compared against the rate in other Australian hospitals, shown in the grey bar.

This graph shows that in 2022 and 2023, the rate of medication errors requiring intervention at Mount Hospital was higher than the industry rate.

What are we doing to reduce the risk of medication errors?

Mount Hospital employs a variety of strategies to reduce the risk of medication errors. These include:

• annual medication competency training for staff involved in medication management
• regular audits covering all aspects of safe medication management
• ongoing staff training by Pharmacists and other relevant professions
• implementation of Healthscope-wide policies and procedures which ensure safe medication management
• use of the Pharmaceutical Benefits Scheme Hospital Medication Chart (PBS HMC) for prescribing medications, in accordance with the Australian Commission on Safety and Quality in Health Care
• labelling of medications as per the National Standard for User-Applied Labelling of Injectable Medicines, Fluids and Lines
• use of Australia’s National ‘Tall Man Lettering’ List in medication store rooms to better distinguish between medications that have similar names
• access to resources that assist with safe medication management, e.g. MIMS Online, Therapeutic Goods Administration, Clinical Excellence Commission and Australian Commission on Safety and Quality in Health Care
• recording of all medication incidents and near misses in the hospital’s incident reporting system
• staff completing a self-reflection tool after any medication incident
• formal review of each medication error to identify contributing factors and prevent it from recurring

What can you as a patient do to help?

We encourage you to bring an up-to-date list of your current medications to hospital with you. This should include the name of the medication, the dose and when, how and why you are taking it. Please give this list to your nurse or doctor when you are admitted. If you bring your own medications into hospital with you, these have to be checked and documented by staff. It is important that you talk to your nurse or doctor if you are uncertain or concerned about any of your medications.

Pressure injuries - commonly known as bed sores - are areas of skin damage caused by prolonged pressure. They can range in severity from an area of reddened skin to ulcers with underlying tissue damage.

Pressure injuries can sometimes occur when a patient remains in one position for a long period. Certain people are at increased risk of developing pressure injuries, such as the elderly, people who are bed-bound or have poor mobility, and people with chronic conditions like diabetes.

This graph below shows the number of patients who have developed a pressure injury during their admission to hospital. The coloured bars represent Mount Hospital's rate. This is compared to the rate of pressure injuries in other Australian hospitals, shown in the grey bar.

This graph shows that in recent years, patients at Mount Hospital have been less likely to develop a pressure injury than patients in other Australian hospitals.

What are we doing to prevent pressure injuries?

Mount Hospital employs a variety of strategies to minimise the risk of patients developing pressure injuries. These include:

• risk assessments to identify patients who are susceptible to pressure injuries
• ongoing education for nursing staff in pressure injury identification, prevention and management
• patient education on prevention of pressure injuries in hospital and at home
• use of pressure-relieving devices such as special mattresses, cushions, wedges, sheepskins, water-filled supports, contoured or textured foam supports, heel elevators and supports filled with gel or beads
• regularly changing patients' position and encouraging walking or movement if possible
• referral to a wound management consultant if a pressure injury is identified
• review of each pressure injury acquired in hospital to assess if there were any preventable factors

A blood transfusion is the transfer of blood or blood products such as platelets or plasma into a patient's vein, usually via an intravenous(IV) cannula. Transfusions may be necessary when a patient

• has lost a large amount of blood
• is unable to produce parts of their own blood
• has blood cells that are not functioning properly

Transfusions are carried out on doctor's orders by trained professional staff, in accordance with the National Safety and Quality Health Service Standards and with the patient's consent. Mount Hospital audits this on a regular basis.

A blood transfusion can be lifesaving or significantly improve quality of life. Australia has one of the safest donor blood supplies in the world, but no blood transfusion is completely without risk. While adverse events are rare, they may include:

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

The graph below shows the number of patients who had a transfusion with no significant adverse event. The coloured bars represent Mount Hospital's rate. This is compared to the rate of successful transfusion events in other Australian hospitals, shown in the grey bar.

This graph shows that in recent years, patients at Mount Hospital have been less likely to have an adverse transfusion event compared with patients in other Australian hospitals.

Some useful resources about blood transfusions are available here.

What are we doing to prevent adverse transfusion events?

Mount Hospital employs a variety of strategies to reduce the risk of adverse transfusion events. These include:

• avoiding unnecessary blood transfusions by use of medications and non-blood treatments
• identifying any risk factors for adverse reactions before the transfusion commences
• careful cross-matching of blood groups to make sure no errors occur
• ongoing training for nursing staff involved in blood transfusion administration
• patient education and provision of written materials explaining blood transfusions
• careful monitoring of patients during administration of a blood transfusion
• working closely with the pathology laboratory that provides the blood
• review of each adverse transfusion event to assess if there were any preventable factors

Healthscope has a national Transfusion Team that oversees best practice standards for transfusion management and reviews adverse events nationally, so that all hospitals can learn from them.

Many operations and procedures performed at Mount Hospital do not require an overnight stay. For minor procedures like colonoscopies and cataract surgery, patients are usually admitted a few hours before their procedure and go home later the same day, after they have recovered from the anaesthetic.

Occasionally, a patient may have an unexpected reaction to the procedure or anaesthetic and will require an unplanned overnight stay or transfer to another hospital.

The graph below shows the percentage of day patients who have required an unplanned overnight stay or transfer to another hospital. The coloured bars represent Mount Hospital's rate. This is compared to the rate of unplanned overnight stays in other Australian hospitals, shown in the grey bar.

This graph shows that patients admitted to Mount Hospital have been less likely to have an unplanned overnight stay compared with patients in other Australian hospitals.

What are we doing to prevent unplanned overnight stays?

Mount Hospital employs a variety of strategies to minimise unplanned overnight stays. These include:

• pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
• careful monitoring of patients during recovery
• use of a consistent process for discharging patients home, to make sure they have fully recovered from the procedure
• review of each unplanned overnight stay to assess if there were any preventable factors

Following a procedure in the operating theatre, patients sometimes need an unplanned second operation. This is called 'return to theatre'. There are many reasons why a patient may require a further operation, such as complications from the first procedure or an unrelated matter.

The graph below shows the percentage of patients who have required a return to theatre after having an operation at Mount Hospital. The coloured bars represent Mount Hospital's rate. This is compared to the rate of return to theatre in other Australian hospitals, shown in the grey bar.

This graph shows that in recent years, patients undergoing surgery at Mount Hospital have been less likely to have an unexpected return to theatre compared with patients in other Australian hospitals.

What are we doing to prevent unplanned returns to theatre?

Mount Hospital employs a variety of strategies to minimise unplanned returns to theatre. These include:

• pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
• careful monitoring of patients in recovery
• review of all unplanned returns to theatre to assess if there were any preventable factors

Following surgery, all patients require close monitoring. This monitoring typically happens in the Recovery Unit. For some major operations, such as heart surgery, an admission to the Intensive Care Unit may be planned to allow monitoring with specialised equipment.

Occasionally, a patient may have an unexpected reaction to the anaesthetic or a complication from surgery and will require an unplanned admission to Intensive Care.

The graph below shows the percentage of patients who have required an unplanned admission to the Intensive Care Unit within 24 hours of their operation. The coloured bars represent Mount Hospital's rate. This is compared to the rate of unplanned admission to Intensive Care in other Australian hospitals, shown in the grey bar.

This graph shows that in recent years, patients admitted to Mount Hospital have been more likely to have an unplanned admission to Intensive Care compared with patients in other Australian hospitals. What are we doing to prevent unplanned admissions to Intensive Care?

Mount Hospital employs a variety of strategies to minimise unplanned admissions to Intensive Care. These include:

• pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
• advance bookings of Intensive Care beds for patients who have specific risk factors
• review of each unplanned admission to Intensive Care to assess if there were any preventable factors

Following discharge from hospital, patients may sometimes require an unplanned readmission. There are many reasons why a patient may need to return to hospital, such as a surgical wound infection that occurred after the initial hospital stay.

Good discharge planning can help reduce the rate of unplanned readmissions. This includes making follow-up arrangements, providing patients with clear care instructions and helping them recognise symptoms that require immediate medical attention.

The graph below shows the percentage of patients who have required an unplanned readmission to hospital within 28 days of their first admission. The coloured bars represent Mount Hospital's rate. This is compared to the rate of unplanned readmissions in other Australian hospitals, shown in the grey bar.

This graph shows that in 2023, patients admitted to Mount Hospital were less likely to have an unplanned readmission compared with patients in other Australian hospitals.

What are we doing to prevent unplanned readmissions?

Mount Hospital employs a variety of strategies to minimise unplanned readmissions. These include:

• discharge processes which ensure that patients understand their medications and any post-operative instructions
• arranging appropriate follow-up care and ongoing appointments, e.g. with the General Practitioner or Physiotherapist
• review of each unplanned readmission to assess if there were any preventable factors