HOW SAFETY AND QUALITY IS MANAGED
AT GLEN IRIS PRIVATE HOSPITAL
Managing Safety &
Quality
INTRODUCTION
Glen Iris Private Hospital commenced operating as a Day Endoscopy Centre in 1985. The existing
building was built in 2008 and consists of an underground car park, a lift, 2 operating theatres,
pathology, and consulting rooms.
SAFETY AND QUALITY
Governance
Registration – Department of Health and Human Services
Glen Iris Private Hospital is registered by the Victorian State Government, Department of Human
Services Private Hospital Unit, to provide surgical services as a Day Procedure Centre.
This registration is subject to compliance with the provisions of the Health Services Act 1988 and the
Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013 and any conditions
endorsed.
Ongoing registration involves regular review and assessment by the Department of Health and Human
Services Private Hospital Unit under the Health Services Act, 1988.
Accreditation – Global Mark
Glen Iris Private Hospital is accredited by Global Mark against AS/NZS/ISO 9001:2008 and the National
Safety & Quality Health Service Standards. As part of this program Glen Iris Private Hospital is subject to
yearly review and re certification every three years.
Quality Policy
The Centre aims to be the most outstanding day surgery facility where clients receive the best
outcomes.
The scope of the Management system is as follows:
The provision of endoscopy and surgical services including individualised pre operative medical
consultation and post operative follow up. To enhance customer satisfaction through the effective
application of the system, including processes for continual improvement of the system and the
assurance of conformity to customer and applicable statutory and regulatory requirements.
Philosophy
Glen Iris Private is a healthcare facility dedicated to providing the highest quality patient care, with a
commitment to clinical excellence and safety delivered with personal attention.
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Managing Safety &
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Success Rate
We collect a number of Clinical Indicators and Business KPI’s and these are monitored, reported,
analysed and benchmarked against like facilities to ensure continuous improvements are made.
AUDIT PERIOD JANUARYESTIMATED RATE
NATIONAL BENCHMARK
DECEMBER 2014
GASTROINTESTINAL
ENDOSCOPY
Failure to reach the caecum
0.21%
0.33%
due to inadequate bowel
preparation.
Failure to reach the caecum
0.1%
0.37%
due to diseased colon.
Failure to reach the caecum
0.08%
0.25%
for any other reason.
Treatment for possible
0%
0.038%
perforation postpolypectomy
Treatment for possible
0.02%
0.044%
perforation postcolonoscopy
Post polypectomy
0%
0.083%
haemorrhage
Oesophageal dilatation0%
0.19%
possible perforation
Consumer Partnership
You should be aware of your healthcare rights and responsibilities including the right to receive care
that is of a high quality and is safe. A copy of your ‘Rights & Responsibilities’ is provided in the patient
information brochure and a copy of the Australian Charter of Healthcare Rights is available in our
reception area. The brochure is supplied in English and 25 other languages and we can arrange an
interpreter if one is required, please inform staff if this is the case. Review the ‘Problem with a health
service or the privacy of your health information’ brochure provided in this folder or at
www.health.vic.gov.au/hsc
We value our client’s and their carers and provide then with the mechanism to provide feedback, both
formally and informally. This feedback is treated with the utmost confidentiality and may be provided
anonymously.
If you are not completely satisfied with your treatment and you wish to make a complaint please ask to
speak to our Director of Nursing who is our nominated complaints officer.
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BENCHMARKING PATIENT SATISFACTION
Using an independent patient satisfaction survey (July – September 2014), we asked our past patients
and families about their overall satisfaction with the services they received at Glen Iris Private, our
recent results are displayed below:
Satisfaction with Care, Services and Treatment
Overall Patient Satisfaction
95.6%
91.6%
We have had nil formal complaints lodged in the past twelve months.
How can you help us manage Safety and Quality?
We have developed a Consumer Participation Register to assist us with reviewing publications and
safety and quality data. If you would like to join this group or participate in a consumer interview and
assist us with making improvements please let one of our staff know.
Infection Prevention and Controlling Healthcare Associated Infections
Glen Iris Private Hospital has a comprehensive infection prevention and control program in place. We
use the expertise of an Infection Control Consultant and our facility is regularly audited for compliance
with National infection prevention and control guidelines, Australian Standards for reprocessing of
reusable instruments (AS/NZS 4187) and against the National Safety & Quality Health Service Standards.
All staff undertakes training and we conduct regular audits to ensure compliance and provide
information on hand hygiene to each patient. Our staff have undertaken training in Hand hygiene,
Standards Precautions, Aseptic Touch technique and cleaning of reusable medical devices to minimise
the transmission of infection. As infections can easily spread through contact we encourage you to use
the hand hygiene products at our facility.
Please also advise staff in you or anyone in your family has a current infection so this can be assessed to
minimise transmission to others and review the Healthcare Associated infections consumer fact sheet in
this folder or at www.safetyandquality.gov.au
Success Rate
We have had no reported Infections in the past twelve months
Hand hygiene rate
Audit Period
Audit June 2015
Audit October
2014
Audit April 2014
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Number of
‘Moments’
90
54
Estimated Rates
National benchmark
92%
79%
83%
70%
27
66%
70%
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Medication Safety
Medication Safety is very important to us. Please let staff know if you have any allergies or have had
any adverse reactions to medications and this will be documented in your medical files and will be
shared with other health practitioners including if a transfer is undertaken. Patients will be advised by
their doctor if they are required to cease any medications. You will be asked to document all your
current medications on the hospital admission paperwork. Natural Medicines can also sometimes have
an effect so please ensure you document these on your admission paperwork.
Success Rate
We have had nil medication incidents reported in the past twelve months.
Patient Identification
To comply with the National Standard 5 you will be asked to wear an identification band during your
stay. Your ID band helps us to ensure that you receive the correct care and is used as part of clinical
handover and if a transfer is required. Please check that the information on the band is correct. Staff
members will check your ID band before giving you any medications and prior to undertaking any test or
procedures.
Success Rate
Compliance is monitored by our Medical record and process audits and we are more than happy to
provide these results upon request.
Clinical Handover
Clinical handover involves the sharing of information between staff members involved in your care and
other health practitioners as required, to ensure health team members have the most up to date
information about your health status. You can expect staff to also keep you up to date with your
condition and your feedback is valuable to the health team and will also be included in this process.
Success Rate
Compliance is monitored by our Medical record and process audits and we are more than happy to
provide these results upon request.
Preventing and Managing Pressure Areas
Pressure injuries at Glen Iris Private Hospital may occur when patients lie or sit for a prolonged period in
one position. Patients are advised to ensure they change positions on a regular basis and inform staff of
any concerns on admission or during their stay that may lead to pressure injury. We use a number of
devices to minimise pressure related injury including but not limited to gel pads, PAT slide, slide sheets.
A useful guide to minimising pressure injury is the document titled ‘Move Move Move’ which is included
in this folder or can be accessed bat www.health.vic.gov.au/qualitycouncil
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Success Rate
We have 0% of reported incidences of Pressure injuries in the past twelve months
Recognising and Responding to Clinical Deterioration
Our staff are trained to recognise changes in your health status, but you can assist by staff by alerting
them if you are unwell, become anxious, or if something has changed or has been missed. You can also
assist by answering the staff’s questions as accurately and honestly as possible.
Success Rate
100% of our clinical staff are trained in Basic Life Support
Preventing Falls and Harm from Falls
Falling is the main cause of injury in many clinical settings. You can assist us by:
 Giving us accurate information about your current health status
 Calling for assistance or pressing a call bell if you feel unwell or need to get up form a trolley or
recliner chair
 Always walking in well fitting shoes, never in socks
 Bring any walking aids that you may have and documenting these on the pre admission forms
 Bring hearing aids or glasses with you
 Remembering that you may have had an anaesthetic and you will need to take things slowly
Review the brochure in this folder ‘Checklist – Stay on your feet’ or at
www.health.qld.gov.au/stayonyourfeet/
Success Rate
We have had no reported incidences of Falls in the past twelve months
Would you like further information?
Our Director of Nursing will be very happy to discuss any questions or concerns you may have with our
Safety and Quality.
Please also refer to our website www.giprivate.com.au for information about our facility.
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