Ramsay Surgical Centre
is focused on the delivery of high quality, safe, and effective clinical care. We strive for high reliability and aim to create an environment in which risks and issues are anticipated, identified early, and responded to rapidly.
Ramsay Health Care’s slogan “People Caring for People” was developed more than 25 years ago and has become synonymous with Ramsay Health Care and the way we operate our business. We recognise that we operate in an industry where “care” is not just a value statement, but a critical part of the way we must go about our daily operations in order to meet the expectations of our customers – our patients.
Patient Safety and Clinical Quality Framework
Ramsay Surgical Centre
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.
Assessing these five key areas ensures we track the complete patient experience
Accreditation
Accreditation is an important driver for safety and quality improvement. 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.
Ramsay facilities engage independent accrediting agencies approved by the Australian Commission on Safety and Quality in Health Care.
Staph Aureus Bacteraemia
At Wollongong Private Hospital we aim to minimise the risk of infection to patients, staff and visitors who come to our facility. This hospital has a number of programs in place to detect and prevent infections that are common within health care facilities.
One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands.
Infection Rate (Staph Aureus Bacteraemia)
Lower score is better
Wollongong Private Hospital
Industry Benchmark Rate
C. Difficile
Clostridium difficile – is an infection of the bowel that causes diarrhoea and does not cause problems in healthy people. Ramsay Health takes every precaution to prevent these infections from occurring in patients during hospitalization through a well-established infection prevention program.
However, if an individual is unwell, taking antibiotics, taking some cancer medications or medications to supress gastric acid, they may be more likely to contract Clostridium difficile. These infections can be acquired in the community (community acquired) or during your admission (hospital acquired).
The chart shows a breakdown of these infections and where the infection was contracted, as knowing where the infection started can help us prevent the spread to other patients.
Clostridium difficile
Lower score is better
Wollongong Private Hospital
Industry Benchmark Rate
C diff - hospital acquired
C diff - present on admission
Hand hygiene is conducted in accordance with the ‘five moments’ that is; before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment.
Wollongong Private Hospital participates in the national hand hygiene strategy through Hand Hygiene Australia. Hand hygiene audits are conducted three times per year.
Visitors to this hospital are encouraged through appropriate signage to use antiseptic hand rub located throughout the hospital.
Hand Hygiene
Higher score is better
Wollongong Private Hospital
Industry Benchmark Rate
The Hand Hygiene brochure has more information on hand hygiene.
The risk of falling increases according to age with data suggesting that one third of people over the age of 65 years have one or more falls a year.
Whilst falls can occur at all ages, the frequency and severity of falls- related injuries increases significantly with age. These injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries may result in hospitalisation or an increased length of stay in hospital.
The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medications and walking in unsafe footwear or slippers.
In 2015 Ramsay increased the focus on falls prevention in hospitals by appointing a National Falls Prevention Advisory Group. This group has standardized the approach to falls prevention across all Ramsay hospitals by targeting a structured risk assessment, policy and guidelines, equipment for falls prevention and clinical staff education. Our hospitals use a number of strategies to prevent falls and these include: targeted hourly rounding of patients identified as high risk of falling; ensuring that call bells and personal items are within patient reach; call bells are answered promptly and patients are assisted to the toilet at regular intervals. In addition, Ramsay has purchased low beds, falls mats, and patient alarms to minimise the risk patients falling whilst in our hospitals.
All Patient Falls
Lower score is better
Wollongong Private Hospital
Average Industry Rate
Patient Falls resulting in fracture or head injury
Lower score is better
Wollongong Private Hospital
Average Industry Rate
Our Falls Prevention brochure entitled 'Keeping on your Feet' has more information on preventing falls.
Our hospital reviews patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge planning processes.
Unplanned Readmissions within 28 Days
Lower score is better
Wollongong Private Hospital
Average Industry Rate
Ramsay Health Care doctors undertake surgery in many specialty areas which range from minor procedures to more complex surgery requiring specialised care. We monitor our patient outcomes by comparing any unplanned returns to theatre to other Australian hospitals nationally. The aim is to reduce returns to theatre where possible; however there are many factors which influence these returns and sometimes these returns may save a life.
Unplanned returns to the operating theatre are frequently due to complications, for example to treat bleeding or other problems occurring early after the operation. Some complications following complex surgery are to be expected due to patients’ pre-existing diseases or conditions and the nature of the disease or condition being treated. Our hospitals monitor all returns to theatre and implement any quality measures which may be required so that our patients get the possible outcomes following surgery.
Unplanned Return to Theatre
Lower score is better
Wollongong Private Hospital
Average Industry Rate
Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors. Wollongong Private Hospital is continually reviewing and implementing a range of medication safety strategies to further improve performance in this area.
The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and Wollongong Private Hospital has adopted many of these strategies. This includes the National Inpatient Medication Chart which standardises the documentation on how medicines are prescribed and ordered. Adoption by Wollongong Private Hospital of the User-Applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered.
In addition, Wollongong Private Hospital has medication administration policies and processes in place which have been developed using best practice principles.
Wollongong Private Hospital takes all medication errors very seriously. We encourage staff to report all errors no matter how minor they may seem. All medication incidents are investigated and actioned. Any serious medication incidents are investigated thoroughly and monitored by the national Clinical Governance Unit.
Medication Safety Errors
Lower score is better
Wollongong Private Hospital
Average Industry Rate
Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.
Wollongong Private Hospital is well equipped with the latest equipment to assist staff to prevent these injuries from occurring. Patients are risk-assessed on admission using an evidenced-based tool. Staff follow a care plan which is targeted to minimising a patient’s risk of developing a pressure injury for those patients assessed as high risk. This includes inspecting the patient’s skin frequently, managing moisture, keeping the skin dry, optimising nutrition and hydration and moving the patient frequently or using special pressure relieving mattresses when needed.
Patients Developing Pressure Injuries Whilst in Hospital
Lower score is better
Wollongong Private Hospital
Average Industry Rate
Our Pressure Injury Prevention brochure has more information on preventing pressure injuries.
As part of your hospital admission, you may require a blood transfusion, which is a procedure where you receive blood through an intravenous cannula in your vein. Blood transfusions may be necessary for a number of reason for example: if you have a surgical procedure, you are anaemic or if your body is not producing sufficient blood cells. Blood transfusions can be a lifesaving measure, but is not without some risk and therefore are only prescribed after a doctor has deemed it necessary. Sometimes an adverse reaction to blood transfusion can occur and is treated immediately. Blood transfusion administration and management are governed by the Australian Commission on Safety and Quality in Health Care Standard for Blood and Blood products.
The graph shows the percentage of transfusion with adverse outcomes.
Blood Transfusions with Adverse Outcomes
Higher score is better
Wollongong Private Hospital
Average Industry Rate
For all babies delivered at our Ramsay maternity facilities an Apgar score is completed for each infant at one minute and again at five minutes after birth. The Apgar score is a simple assessment of how a baby is at birth, which helps determine whether the newborn is ready to meet the world without the need for additional medical assistance. It is determined by five characteristics of the baby – heart rate, breathing effort, muscle tone, reflex irritability and skin colour. Each characteristic is rated from zero to two and the sum of these five characteristic is the total Apgar score of the baby. The rating scale is from 1 –10 with 7 and above being considered normal and the baby is in good health. If the Apgar score is < 7 then it is indicating that the baby requires further attention and support from the health professionals present. Ramsay Maternity Hospitals have less babies requiring additional support in comparison to other maternity hospitals, this means we have healthy babies at birth.
Babies born with a Healthy APGAR Score
Higher score is better
Wollongong Private Hospital
Average Industry Rate
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.
Please note: the presence of an asterisk (*) beside the Net Promoter Score indicates less than 25 surveys were returned during the reporting period, which reduces statistical relevance.
Our Net Promoter Score:
72
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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