Tweed Day Surgery

MyHealthscope - Quality and Safety

At Tweed Day Surgery, we take quality and safety seriously.

To provide you with information about our performance, Tweed Day Surgery publishes data which measures the quality and safety of our services. This is only one part of our program to continually maintain and improve our high standards. It reflects our commitment to our patients, staff and specialists, in line with Healthscope's Purpose: We work together for better care.

At Tweed Day Surgery, quality is not just one simple measure. It involves many aspects of care and of a patient's experience.

Please click on the menu below to view data for each of the indicators we publish.

Tweed Day Surgery 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. In addition, the hospital is certified against ISO 9001 2015, an international standard to help organisations ensure they meet the needs of customers and comply with statutory and regulatory requirements.

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 ISO 9001 2015 and the eight overarching NSQHS standards with many different criteria, including patient-centred care, medication management, clinical handover, infection prevention and staff education.

At the most recent survey in February 2018, Tweed Day Surgery achieved full accreditation. The hospital's accreditation report can be viewed here.

At Tweed Day Surgery, 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 Tweed Day Surgery'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.

Tweed Day Surgery'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 about patient experience is 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 the most recent quarter.

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

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

This graph shows that 'very good' ratings have been consistently above 90%. [Data correct as at 19 February 2020.]

Net Promoter Score

Another key question we ask our patients is “How likely is it that you would recommend this hospital to a family member, friend or colleague?” Patients can rate their response on a scale of 0 (extremely unlikely) 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 Tweed Day Surgery during the most recent quarter. The higher the score, the more patients would recommend the hospital. Scores above 50 are considered ‘excellent’.

[graph under development – to be added soon]

This graph shows that the NPS at Tweed Day Surgery during the most recent quarter was xyz.

What are we doing to improve patient experience?

Tweed Day Surgery 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

Tweed Day Surgery 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 Tweed Day Surgery 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 Tweed Day Surgery'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 SAB infections at Tweed Day Surgery 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 Tweed Day Surgery. This is compared to the rate in Australian public hospitals, as shown in the grey bars.

[graph to be added]

This graph shows that the rate of MSSA and MRSA infections at Tweed Day Surgery is very low and lies well below the rate in Australian public hospitals.

What are we doing to prevent infection?

Tweed Day Surgery 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 Tweed Day Surgery, 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 has not 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:

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 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 Tweed Day Surgery, 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 Tweed Day Surgery's rate. This is compared to the Australian national benchmark of 80%, shown in the grey bar.

This graph shows that hand hygiene compliance at Tweed Day Surgery lies well above the Australian national benchmark.

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 groups within the hospital. The graph shows that compliance rate for nursing staff is higher than for other groups.

What are we doing to improve hand hygiene compliance?

Tweed Day Surgery 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 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
  • use of specially designed washbasins where water can be turned on and off without touching the tap

What can you do to help?

At Tweed Day Surgery, 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:


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 the rate at Tweed Day Surgery. This is compared to the rate of falls at other Australian hospitals, shown in the grey bar.

This graph shows that patients at Tweed Day Surgery have 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?

Tweed Day Surgery employs a variety of strategies to minimise the risk of patients falling. 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 Tweed Day Surgery, 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 Tweed Day Surgery. 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 Tweed Day Surgery 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 Tweed Day Surgery. This is compared against the rate in other Australian hospitals, shown in the grey bar.

[graph under development – to be added soon]

This graph shows that the rate of medication errors at Tweed Day Surgery is very low and lies well below the industry rate.

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

Tweed Day Surgery 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.

Most operations and procedures performed at Tweed Day Surgery 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 Tweed Day Surgery'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 Tweed Day Surgery are less likely to have an unplanned overnight stay or transfer to another hospital compared with patients in other Australian hospitals.

What are we doing to minimise unplanned overnight stays?

Tweed Day Surgery 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 in 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. The coloured bars represent Tweed Day Surgery's rate. This is compared to the rate in other Australian hospitals, shown in the grey bar.

This graph shows that patients undergoing surgery at Tweed Day Surgery are less likely to have an unexpected return to theatre compared with patients in other Australian hospitals.

What are we doing to minimise unplanned returns to theatre?

Tweed Day Surgery 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

Tweed Day Surgery supports transparent public reporting of healthcare quality data and actively participates in initiatives of the following organisations.

Australian Commission on Safety and Quality in Healthcare (ACSQHC) – The Australian Commission on Safety and Quality in Healthcare (the Commission) was established in 2006 by the Australian, State and Territory Governments to lead and coordinate national improvement in safety and quality. Healthscope has representation on the Private Hospital Sector Advisory Committee and several key working groups.

Australian Institute of Health and Welfare - The Australian Institute of Health and Welfare (AIHW) is a major national agency set up by the Australian Government under the Australian Institute of Health and Welfare Act to provide reliable, regular and relevant information and statistics on Australia's health and welfare.

MyHospitals Website – This website lists all public and private hospitals in Australia, along with information about waiting times for elective surgery and emergency department access. Healthscope has representation on the MyHospitals Development Advisory Committee.

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