Safety and Quality
Statement
Castle Hill Day Surgery is committed to providing safe and high quality services, and
maintains certification against the National Safety and Quality Health Service Standards
(NSQHSS) and ISO 2008:9001 – Quality Management Systems. We employ the
services of an independent auditor (Global Mark) to verify our continued
compliance against the wide range of standards and legislation (including the National
Safety and Quality Health Service Standards) relevant to hospitals at all times. This
page gives details on how the hospital meets the NSQHS standards and includes
current data on CHDSs performance.
Governance for Safety and Quality in Health Care
CHDS has an organisation wide management system that includes a Core
Management Committee, and Medical Advisory Committee. Working within a quality
management framework, these committees ensure that clinical practice is bound in
evidence, clinicians are trained well and maintain high levels of performance, feedback
and incidents are analysed and used to improve services, and that consumers of our
services are engaged at all levels.
CHDS was successfully accredited against this standard and maintained ISO
2001:9008 as assessed by Global Mark in 2013 and 2014.
Partnering with Consumers
CHDS involves both patients and carers in a variety of ways. The information in this
document, our website and other printed material that we give to you, and the advice we
give over the phone is tested with a consumer survey process, made up from people
who have been our patients or have been involved in their care.
How we are managing against other centres is displayed in this folder. This is known as
benchmarking, and our reviewer QPS Benchmarking Services information is included
here.
Safety and Quality for Patients August 2015
Preventing and Controlling Healthcare Associated Infections
We take the prevention and control of healthcare associated infections seriously, and go
to extraordinary lengths to minimise the risks to our patients and our staff. The hospital
uses disposable equipment where possible, and our reusable instruments are cleaned
and decontaminated or sterilized using highly advanced methods.
The hospital also uses proven methods to reduce the risk of transmission of infection by
social contact, and fully participates in Hand Hygiene Australia initiatives. You can see
how we are performing by viewing our audit outcomes displayed in this folder
In recent times there has been an increase in the number of infections that are resistant
to many antibiotics. We do our part to slow the evolution of the bacteria that cause
these infections by using antibiotics suited to each patient’s particular circumstances.
Medication Safety
Patients are at an increased risk of being harmed by mistakes with medications or
having unexpected reaction to a medication in any healthcare setting. At CHDS, we
minimize the risk of this happening by following strict protocols when giving you
medicines. These protocols involve many repetitious questions which can become an
annoyance, but they are essential for our patients safety. In the unlikely event you have
an unexpected reaction to a medication, we will manage any side effects that result, and
will undertake a thorough analysis of what went wrong. If this reveals that you have an
allergy or suffer unexpected side effects from a medication we give to you, we will
provide information on managing this in the future for you and your general practitioner.
When we ask you if you have any allergies, it’s important that you tell us, even if you
may have told someone else during your stay. We need to know about all allergies
including any to food, as some food allergies have a link with medication allergies that
you may not be aware of.
Patient Identification and Procedure Matching
Safety and Quality for Patients August 2015
We make sure that when patients are unable to answer for themselves, the information
we have on file is correct. This helps us make the right decisions. To do this, we gather
much information and perform many checks before and during admission. Some
checks are performed in the procedure or operating room itself during what clinical staff
call a “Time Out.” Among other things, we ask patients to confirm who they are, and
what they are intending to have done. These questions and checks are some of many
that are recommended by the World Health Organisation to minimise the risks of
making a serious mistake in the procedure room.
Clinical Handover
When complex information is passed from person to person, important details can be
lost. To prevent this happening at CHDS, we have strict policies on how information
relating to patients is passed from one individual to another, and use specifically
designed forms and templates to communicate this information within the Hospital and
to other healthcare services.
Blood Products
Because of the types of procedures and surgery undertaken at CHDS, we do not
routinely administer blood or blood products to patients.
Preventing and Managing Pressure Injuries
As patients do not stay at CHDS for an extended period of time the risk of developing
pressure injuries is extremely low. We do however take precautions to prevent the risk
of a patient developing a pressure injury, which can develop over time in individuals
who are unwell, spend a lot of time in a chair or bed, or have fragile skin. During
admission patients are assessed for risk factors that could increase the likelihood of a
pressure area forming such as the ones above, and steps are put in place if required.
Safety and Quality for Patients August 2015
Recognising and Responding to Clinical Deterioration in Acute Health Care
While rare, patients can have unexpected complications during or after a procedure or
surgery. When complications occur, there is a direct link between the speed at which
they are detected and treated and the outcome of the patient. At CHDS, staff regularly
receive advanced training to recognise and manage these complications. They also
used specially designed forms and cutting edge technology to monitor patients progress
over time, ensuring any complications that develop slowly are recognised and managed
quickly.
Preventing Falls and Harm from Falls
Most people are steady on their feet when going about their usual day-to-day activities.
But being in an unfamiliar environment such as a hospital, and having received sedative
or anaesthetic medications, a person’s risk of falling and injuring themselves increases.
If a patient suffers an existing disability in addition, these risks increase dramatically. At
CHDS, patients are assessed for their risk of falling during admission, and steps are
taken to minimise the chance of this occurring. After a patient has been given sedation
or anaesthetic, they will be monitored when moving about by themselves, and offered
assistance or mobility aids if required. This is also one of the reasons we require all
patients who have had sedation or anaesthesia to be accompanied by a responsible
adult for 24 hours.
Safety and Quality for Patients August 2015
BENCHMARKING REPORT:QPS BENCHMARKING: 2015
Title
Better
than
Bench
mark
% Variation
from last
result.
Patient Based Cancellations
-34.137%
Patient Waiting Time General
6.01%
Length of Stay - General
-8.617%
Post-operative Nausea and/or
Vomiting - General
-42.647%
Facility Cancellations
-66.896%
Patient Incidents & Near
Misses
-26.288%
S8 & S4 Drug Audit
N/A
Medication Errors
0%
Written Complaints
0%
Verbal Complaints
-50.515%
Agency Staff Usage
0%
Quarter 2
Title
Better
than
Bench
mark
% Variation
from last
result.
Patient Based Cancellations
25.131%
Patient Waiting Time General
4.731%
Length of Stay - General
2.505%
Clinical Record Audit
9.032%
Facility Cancellations
97.917%
Patient Adverse Events
-56.886%
Medication Errors
0%
Infection Prevention & Control
-2.24%
Safety and Quality for Patients August 2015
System Assessment
Written Complaints
0%
Verbal Complaints
100%
Credentialing of Healthcare
Professionals
0%
Fire & Safety Equipment
Audit
3.158%
Quarter 3
Title
Better
than
Bench
mark
% Variation
from last
result.
Patient Based Cancellations
-49.79%
Patient Waiting Time General
3.15%
Post-operative Length of Stay
(LOS) - General
4.981%
Post-operative Nausea and/or
Vomiting - General
107.986%
Facility Cancellations
-100%
Medication Errors
0%
Written Complaints
152.084%
Verbal Complaints
-37.5%
Competency Testing for Fire
and Emergency Skills
-1.065%
Safety and Quality for Patients August 2015