Our Performance in Clinical Safety and Quality
RHC's performance in patient safety and quality care is the highest priority for us as an organisation. We use clinical and patient experience data to identify high performance, evaluate how reliable and consistent patient experiences are, to reduce unwarranted variation and to drive opportunities for improvement. We translate clinical data into current outcomes, trends over time and evaluate improvement opportunities. Most importantly we are transparent and strive to provide you the patient with the information you need to make an informed decision that is right for you.
In order to measure our performance and truly know how our performance translates to patient outcomes and experience we need to gather information from a range of sources. For example, we gather data from clinical incident reporting, clinical outcomes, audits, patient experience surveys, patient feedback, clinical registries and clinical indicator sets that compare standardised outcomes both internally and externally (benchmarking). Here at Ramsay Health Care we have robust processes to ensure clinical outcome data is reviewed in time frames relative to the risk, the greater the risk the more frequently and immediate our review. We have systems that ensure information is escalated to the highest level of the organisation if they pose an imminent risk to patients' safety. Otherwise we review clinical performance at monthly, quarterly and half yearly intervals. Here at RHC we also have systems to ensure patient outcome data is cascaded down to our frontline staff as well as escalated up to the highest levels of governance of the organisation
Your Safety, Our Care
Murray Valley Private Hospital
is centred on People Caring for People. Our aim is to ensure you receive high quality, safe and effective clinical care whilst in our facilities. We are committed to providing excellence in all our services and look for opportunities to improve at each stage of journey with us.
Ramsay Health Care hospitals, facilities and services all hold the necessary accreditation with the relevant authorities. Accreditation is one way we assure the community that Ramsay Health Care meets the high standards set for health service providers and the level of care that consumers can expect from our services.
Patient Safety and Clinical Quality Framework
Murray Valley Private Hospital
operates under Ramsay Health Care’s comprehensive Patient Safety and Clinical Quality Framework which consists of five key areas designed to produce reliable, safe, and effective outcomes:
Click on the interactive framework for more details about each section
People Caring for People
Ramsay Health Care Australia is centred on People Caring for People.
Our Framework reflects the central role our staff, credentialed
clinicians, consumers, patients and their families, play in the provision
of high quality clinical care.
- Patient and Consumer Experience
The organisation routinely collects and publishes data on patient and consumer experience, action plans are
developed to address feedback, and strategic and business planning are informed by patient and consumer
experience.
- Staff Engagement and Staff Health
The organisation routinely collects data on staff engagement, action plans are developed to address feedback, and
strategic and business planning is informed by staff feedback. The organisation has a coordinated approach to, and
ongoing support for, a comprehensive staff health program.
- Involving consumers and patients in safety and quality
Consumers, patients, and their families, are actively engaged in the planning of quality and safety processes
including participation in quality improvement initiatives and service planning; their input into committees and
advisory panels is sought.
- Open Disclosure
Following an adverse event, consumers and patients are supported and openly informed of what occurred.
The organisation ensures that staff and credentialed clinicians are effectively supported to participate in the open
disclosure process.
- Complaints Management
Consumer and patient complaints are managed in a timely and effective manner to ensure resolution. Information
from the complaints management processes is utilised to inform organisational improvement strategies.
Continuous Improvement
Ramsay Health Care Australia recognises the requirement for
continuous improvement to ensure safe and effective clinical
outcomes. The encouragement of local improvement initiatives,
identification and dissemination of best practice, use of data for
improvement, and consideration of human factors are supported
across the organisation.
- Spread and Sustainability of Best Practice
The identification and dissemination of best practice is encouraged across the organisation. The promotion of
policy, procedures, care pathways, and models of care which ensure high quality, safe and effective outcomes for
patients is supported to reduce variation and ensure the consistent application of best practice.
- Data for Improvement
The use of data to identify high performance and opportunities for improvement is encouraged. Transparency
in reporting is embedded across the organisation, and reported patient safety and clinical quality data includes
reliability measures, both process and outcome measures, and is appropriately benchmarked wherever possible.
- Human Factors Design
Human Factors is recognised in system redesign and capital changes to minimise the impact on system safety.
Education and training of the workforce in human factors design is available. Human factors design is considered in
the implementation of changes to clinical and organisational practice.
- Improvement Initiatives
The workforce is encouraged to identify the opportunity for, development and implementation of, local
improvement initiatives. Support for improvement initiatives is provided, including the provision of education and
training in improvement science. Quality improvement initiatives are recognised across the organisation.
Culture for Safety and Improvement
Ramsay Health Care Australia recognises a positive safety culture and a
focus on effective teamwork and resilience can reduce adverse events
and improve clinical outcomes. To ensure high quality and safe care,
Ramsay Health Care Australia promotes a culture that encourages and
supports: the reporting of, and learning from, incidents; building effective
leaders and clinical teams; and, staff and credentialed clinicians to speak
up for patient safety.
- Speak up for Patient Safety
A culture that supports all staff, both clinical and non-clinical, and credentialed clinicians to speak up when then they
perceive a patient to be at risk is encouraged and promoted. The Vanderbilt framework for Promoting Professional
Accountability is adopted across Ramsay Health Care via our Speak Up for Patient Safety initiative.
- Team Effectiveness
The implementation of team based improvement initiatives are encouraged. The organisation supports openness,
transparency and analysis of incidents to provide team based learning opportunities. Practices to support effective
team work are encouraged including team based bedside clinical handover, active patient rounding, and the
implementation of safety huddles.
- Leadership
The development of effective clinical leaders, and identification of emerging clinical leaders, is promoted across the
organisation. Leadership training is provided and practises of effective leaders are encouraged including executive
walk rounds.
- Building Workforce Capability
The training and development of the workforce in patient safety and clinical quality initiatives is recognised as
essential, and is supported across the organisation. The roles and responsibilities for the workforce in relation to
patient safety and clinical quality are well defined in role descriptions.
Structure and Processes for Clinical Safety
Ramsay Health Care Australia has established robust structures and
processes for the establishment and monitoring of clinical governance
processes across the organisation.
- Accreditation
All Ramsay facilities undergo formal accreditation processes against the National Standards for Safety and Quality in
Health Care. Action plans to address any identified gaps are developed and implemented.
- Credentialing
All applicable clinicians are subject to formal credentialing processes. Scope of practice for individual clinicians is
aligned to recognised skills, facility licenses and organisational service capability.
- Policy and Procedures
An informed and systematic approach to the development and implementation of policy and procedure is applied.
All policies and procedures are based on best available evidence to ensure safe, consistent, and effective clinical
care.
- Reporting for Clinical Safety
An effective committee structure ensures reporting on patient safety and clinical quality occurs at the highest level
of organisational governance, including to Risk Management and the Board.
- Facility Rules
A comprehensive set of facility rules are applied to new and existing credentialed clinicians to ensure the roles and
responsibilities of both the clinicians and Ramsay Health Care are explicit.
Minimising Harm and Preventable Mortality
Ramsay Health Care Australia recognises that on rare occasions
adverse events occur; we aim to build a high reliability system
through the comprehensive analysis of incidents, sharing of lessons
learnt, establishment of robust Morbidity and Mortality reviews and
implementation of evidence based care.
- Effective Clinical Incident Management
Reporting of all clinical incidents and near misses is encouraged, and timely investigation of incidents to identify
root causes, contributing factors, and system improvement opportunities occurs. Systems are established to
ensure recommendations arising from incident investigations are implemented and their effectiveness monitored.
Consumers, patients, staff and credentialed clinicians are informed of the outcomes of incident investigation
processes.
- Morbidity and Mortality Processes
All consumer and patient morbidity and mortality, and outcomes of clinical care, are subject to critical analysis by the
clinical team with an emphasis on the identification of system improvement opportunities. Actions to address any
issues identified are developed and monitored.
- Sharing Lessons Learnt
Identification of internal and external key clinical risks, issues, and resulting strategies for improving the safety of the
system, are systematically shared across the organisation.
- Building System Reliability
The development, implementation, and monitoring of evidence based care, care bundles, and patient safety
processes are supported across the organisation to minimise unwarranted clinical variation and clinical risk.
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Clinical Quality & Safety Results
Infection%20Rates
Healthcare-associated S. aureus bloodstream infections per 10,000 days of patient care (a lower rate is better).
Hand Hygine
Our rate
96.100%
Is our overall rate of compliance with the national hand hygiene initiative (a higher rate is better).
Patient Falls
Our rate
0.436%
Patient falls per 100 days of patient care (a lower rate is better).
Medication Errors
Our rate
0.000%
Medication errors requiring intervention per 100 days of patient care (a lower rate is better).
Net Promoter Score
Ramsay Health Care is committed to providing excellent care and encourages patients to be proactive partners in this endeavour.
For this reason we conduct Net Promoter Score surveys among our patients to understand how well we are meeting expectations, and to identify any areas needing improvement. These surveys are independently conducted by a third party through our private medical surgical facilities in Australia and the results are published quarterly.
Our Net Promoter Score:
71*
*Less than 25 surveys were returned during the reporting period, which reduces statistical relevance.
What does the survey ask?
Patients are asked:
Based on your recent experience, how likely are you to recommend us to your friends and family?
Depending on the rating (from 0 to 10), patients are asked to provide more information to explain their experience.
Calculating the Net Promoter Score
Respondents are grouped into three categories:
- Promoters: a score of 9 to 10
- Passive: a score of 7 or 8
- Detractors: a score of 0 to 6
The Net Promoter Score is calculated by subtracting the percentage of Detractors from the percentage of Promoters. The final
score can range from -100 (if every patient is a Detractor) to 100 (if every patient is a Promoter)
Initiatives to improve your care
An initiative that allows patients, their relatives, or carers, to call for rapid assistance when they believe something is ‘not right’ with the clinical condition of the patient.
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An evidence-based framework which escalates awareness of patient safety and encourages staff to challenge potentially risky behaviour.
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