The Victoria Clinic 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 2022, The Victoria Clinic passed all 133 applicable criteria and achieved full accreditation. The hospital's accreditation report can be viewed here.

At The Victoria Clinic, 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 Your Experience of Service survey (YES) developed by the Australian Government Department of Health for mental 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 The Victoria Clinic'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.

The Victoria Clinic'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 experience of care, which can be rated on a scale of 1 to 5, from 'poor' to 'excellent'. The graph below shows the patients' responses during 2023.

This graph shows that the majority of our patients have rated their overall experience of care as 'excellent' or 'very good'.

The graph below shows the percentage of patients at The Victoria Clinic who have rated their overall experience of care as 'excellent' or 'very good' (top two boxes) since this option was first introduced.

This graph shows that the percentage of patients rating their experience of care at The Victoria Clinic as 'excellent' or 'very good' has been variable. [Data correct as at 19 March 2024]

Net Promoter Score

Another key question we ask our patients is “If they needed mental health care how likely is it that you would recommend The Victoria Clinic 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 The Victoria Clinic 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 The Victoria Clinic in 2023 was 41.4.

What are we doing to improve patient experience?

The Victoria Clinic employs a variety of strategies to improve patient experience. These include:

• hospital management monitoring the feedback provided by patients - including the ratings of overall treatment and care - and taking action to address any areas of concern
• ongoing staff education and program development to ensure that care is person-focused, meets patients' needs and is of the highest standard
• employing Consumer Consultants to engage with patients and families and provide feedback from a patient's or carer's perspective
• involving patients in their care, for example by encouraging their participation in shift handover and community meetings
• consulting with Healthscope's National Patient Experience Manager to assist the hospital in implementing strategies to enhance patient experience

At The Victoria Clinic, we measure the mental health of patients on admission and again on discharge, to see how they are improving. We use the internationally recognised HoNOS (Health of the Nation Outcome Scales), a tool which allows clinicians to assess various aspects of a patient's mental health, such as depression, anxiety or problematic behaviour.

The graph below shows the decrease in mental health problems in patients after treatment. The dark coloured bars represent mental health problems on admission to The Victoria Clinic. The pale coloured bars represent mental health problems on discharge. This is compared to the outcomes at other Australian private mental health facilities, shown in the grey bars.

HoNOS Scores

This graph shows that patients' mental health problems have decreased after treatment. On average, patients at The Victoria Clinic have achieved improvement similar to patients at other Australian private mental health facilities.

Mental Health Questionnaires

It is also important to ask patients whether they think their mental has improved during their hospital admission. This is part of collecting patient-reported outcome measures (PROMs) and an important method of obtaining feedback on our services. We use the MHQ-14 (Mental Health Questionnaire), a PROMs tool, which asks questions about symptoms of fatigue, anxiety and depression and the impact of those in daily life.

The graph below shows the improvement in patients' self-assessed mental health ratings. The dark coloured bars represent the rating on admission to The Victoria Clinic. The pale coloured bars represent the ratings on discharge. This is compared to the outcomes at other Australian private mental health facilities, shown in the grey bars.

This graph shows that patients feel that their mental health has improved after treatment. Patients at The Victoria Clinic have achieved improvement similar to patients at other Australian private mental health facilities.

What are we doing to improve mental health outcomes?

The Victoria Clinic employs a variety of strategies to improve our patients' mental health outcomes. These include:

• individualised, comprehensive, collaborative and goal-orientated care planning
• a multidisciplinary approach, including expert nursing and allied health professionals
• group therapy, counselling and other kinds of therapy
• regular review of patient medication to ensure it is optimal
• involving family and carers in treatment, with the patient's consent

If you are worried about your mental health, or that of someone close to you, there are people who can help you right now:

• Lifeline Australia - 13 11 14
• Kids Helpline - 1800 55 1800
• Mens Line Australia - 1300 78 99 78
• Suicide Call Back Service - 1300 659 467
• Beyond Blue - 1300 224 636
• Veterans and Veterans' Families Counselling Service - 1800 011 046

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

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

One of the infections that we closely monitor at The Victoria Clinic 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 The Victoria Clinic'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 there have been no cases of SAB infections at The Victoria Clinic in recent years.

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 The Victoria Clinic. This is compared to the rate in Australian public hospitals, as shown in the grey bars.

This graph shows that there were no MSSA or MRSA infections at The Victoria Clinic during the reporting period.

What are we doing to prevent infection?

The Victoria Clinic 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 The Victoria Clinic, 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

• 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 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 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 The Victoria Clinic, we use auditors 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 The Victoria Clinic'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 for different staff within the hospital. It shows that the compliance rate for all professional groups has been very high.

What are we doing to improve hand hygiene compliance?

The Victoria Clinic 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
• specially designed washbasins where water can be turned on and off without touching the tap

What can you do to help?

At The Victoria Clinic, patients and visitors are part of the health care team. Good hand hygiene is the most important way in which you 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 in a weakened or confused state.

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

This graph shows that patients at The Victoria Clinic on average have had a lower rate of falls than those in other Australian hospitals.

As a result of a change of focus in this area we now have a Falls Working Party which includes key staff across the organisation. This group provides education to all staff caring for our patients. In addition, we provide information to patients who may be at risk of experiencing a fall. We have also purchased new equipment for patients who are identified on admission as having an increased risk of falls.

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

What are we doing to reduce patient falls?

The Victoria Clinic 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 walking aids, toilet chairs and extended call bells as required
• review of each fall to assess if there were any preventable factors

What can you do to help?

At The Victoria Clinic, 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 The Victoria Clinic. 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 The Victoria Clinic 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 The Victoria Clinic. This is compared against the rate in other Australian hospitals, shown in the grey bar.

This graph shows that there have been no medication errors requiring intervention at The Victoria Clinic in recent years.

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

The Victoria Clinic 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.