Patient Safety and Quality

North Lakes Day Hospital's Commitment to Patient Safety and Quality

North Lakes Day Hospital is committed to providing the highest quality healthcare, with a core focus on each patient’s experience. Providing the safest possible care whilst achieving the desired patient outcomes is reflected in our:

  • Day-to-day operations
  • Corporate and clinical governance
  • Support systems in place for our clinicians, nurses and broader workforce
  • Workplace culture and values

Montserrat Day Hospitals is the National healthcare provider we are owned and operated by. We utilise Montserrat’s robust Quality Management System (QMS) and clinical governance framework to manage the care and services we provide.

The Montserrat Day Hospital QMS is designed to monitor care outcomes, patient satisfaction and safety initiatives, manage and mitigate risks, and identify training requirements for our staff across the National Safety and Quality Health Service Standards. This system is supported by continual investment in state-of-the-art medical equipment and a highly skilled team of clinicians, nurses and support staff. All Montserrat hospitals perform various audits for compliance as per our accreditation and licensing requirements.

We report on a variety of quality scorecard indicators including:

  • Patients’ experience and feedback
  • Hand hygiene compliance rates
  • Surgical site infections
  • Fall rates
  • Medication safety
  • Unplanned returns to theatre

At all times we uphold the National Safety and Quality Health Service Standards (NSQHS) – the national benchmark that all hospitals Australia-wide must meet to maintain their licensing and accreditation status.

Learn more about our approach to the National Standards below and how we implement Montserrat’s QMS and clinical governance framework to deliver quality healthcare locally.

North Lakes Approach to the Eight National Safety & Quality Health Service Standards

North Lakes Day Hospital gathers important data across all aspects of our hospital to continuously improve the safety, effectiveness and quality of our services. We use clinical governance systems across all levels of our organisation to achieve, monitor and regularly review our safety and quality performance.

Our entire workforce – nurses, clinicians, management, the board of Directors and support staff have accountability to patients at North Lakes and the broader community for ensuring the delivery of our healthcare is safe, effective, integrated, high quality and continuously improving. That is our commitment.

North Lakes Day Hospital partners with select consumers and patients as this has proven beneficial in the planning, design, delivery, measurement and evaluation of our hospital. We place great importance on these partnerships as they help to guarantee quality patient outcomes and safety standards, whilst also benefiting patients’ carers and families, our clinicians and more broadly the healthcare industry. These partnerships exist across the following three levels:

  1. The relationship between North Lakes’ clinician and patient at the point of care; a relationship founded on our values of respect, integrity, collaboration, innovation and compassion.

  2. Patients, carers, families and consumers’ involvement in planning, implementing and evaluating change at the department level.

  3. Consumers or patients’ involvement in the governance, policy and planning of our healthcare service. Key areas focused on at this level include patient safety, facility design, quality improvement, patient or family education, professional development, ethics and research. Partnerships with the broader community may also occur at this level.

North Lakes Day Hospital has robust systems in place to mitigate the risk of infection, foster good antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources.

We know the best way to stop germs from spreading and have best practice measures in place to support this, particularly with hand hygiene, sterilisation techniques and the use of protective equipment. Our facility is well-maintained and optimised for patient flow. Our systematic approach to preventing, controlling and responding to infections creates a safe environment for all visitors and staff at our facility.

Medicines are the most widely prescribed treatment in healthcare and contribute significantly to improvements in patients’ health when used appropriately.

Accurately and safely prescribing, dispensing and administering the appropriate medicine to patients and monitoring medicine use is a mandatory standard at North Lakes Day Hospital. Our clinicians’ duty of care ensures patients and consumers are informed about and understand their individual medical needs, and associated risks.

Before commencing an episode of care, North Lakes Day Hospital will source a patient’s best possible medication history and have this on record. We ask patients for full disclosure about their medical history, current medications, allergies and adverse drug reactions in our Online Health Assessment to be completed at least three days before admission. Our nurses ensure patients are discharged with all the necessary information including scripts to care for themselves once home.

North Lakes Day Hospital provides continuous and collaborative care to patients in partnership with their healthcare team, carers and families. Our hospital has integrated systems in place supporting our clinicians to deliver comprehensive, quality healthcare whilst mitigating and managing the risk of harm.

All clinicians at our hospital undertake a screening and assessment process with patients to identify potential risks that could be associated with the delivery of healthcare. Patients, their carers and families are consulted as part of this process to develop goal-oriented, comprehensive care plans.

If a patient is at risk of harm, our clinicians will deliver targeted, best-practice strategies to prevent and manage this from occurring. Safely managing transitions between episodes of care, and ensuring a continuum of comprehensive care are standards our clinicians abide by.

One of the best ways we coordinate safe patient care as well as visitor and workforce safety is through communication and documentation. This encompasses communication with our patients, carers and families, multidisciplinary teams and clinicians, and all business units across our organisation.

Effective communication and documentation help to mitigate high-risk situations and manage patient safety. North Lakes has formal processes in place to identify patients, match care to their needs, and appropriately manage clinical handovers when information about a patient’s care emerges or changes.

Whilst there are times when communication (be it informal) in the delivery of patient care will not be recorded, our hospital’s approach is always to formalise the communication and documentation requirements critical to patient safety at key times during the delivery of care.

North Lakes Day Hospital uses a combination of clinical governance and quality improvement systems to appropriately manage a patient’s own blood, as well as any blood or blood products.

As part of the Montserrat Day Hospital group, we have strategies and procedures in place to accurately manage the availability and safety of blood and blood products. Safety systems are in place and every care is taken to safely administer blood products to each intended recipient, and closely monitor and report any adverse reactions or incidents. This dual approach to blood management and patient care is the most effective way to ensure the appropriate and safe use of blood and blood products at our hospital.

All medical and support staff at North Lakes have a duty of care to recognise and promptly respond to changes in a person’s physiological, cognitive or mental state, otherwise known as acute deterioration. Providing patients with appropriate and timely care is part of our organisation-wide recognition and response system when acute deterioration is identified.

Early detection is critical in these situations as it may improve outcomes and lessen the intervention required when treating the patient. At North Lakes Day Hospital we understand the importance of identifying and acting on the warning signs of clinical deterioration efficiently and appropriately. Management of these circumstances draws on our approach to comprehensive care and communication and documentation for safety.

Having a highly-skilled healthcare team who understand the signs and symptoms that could signal acute deterioration, combined with our safety, quality and patient monitoring systems all help to recognise acute deterioration.

North Lakes Day Hospital's Patient Safety & Quality Management System (QMS) Quarterly Report: October to December 2022

As part of the Montserrat Day Hospital group, North Lakes monitors and reports on a number of quality measures including patient satisfaction surveys and the patient experience, infection prevention and control including hand hygiene compliance rates, patient incidents, medication safety and return to theatre percentiles. The policies, processes, and procedures associated with these areas are embedded in all hospital operations and workflow. Quality management focuses on continuous quality improvement as measured by consumer and patient satisfaction. Our quality structure is unique: it is integrated and further strengthened by our quality-trained nurses and medical staff.

North Lakes Day Hospital Clinical Indicators

  • Patients Experience- Feedback
  • Infection Prevention
  • Monitoring incidents
  • Medication safety
  • Return to theatres monitoring

Patient feedback provides valuable information and not only ensures that patients’ voices are heard, but by examining patients’ feedback it gives direct insight into our quality of care and patient satisfaction.  This aids in maintaining and improving the standard of care offered at North Lakes.  Patients are encouraged to provide feedback using the feedback form provided or by visiting our website.

Consumer satisfaction at North Lakes Day Hospital has been collated and graphed for analysis.  The last quarter shows a perfect satisfaction rate with 100% of all surveyed patients providing positive feedback about their experience.

North Lakes has a formal complaints process should a patient be dissatisfied with the level of specialist care or customer service at our hospital. During October to December 2022, we cared for 968 patients and no complaints were received.

Consumer Satisfaction (Oct to Dec 2022)

Consumer Satisfaction 100%

Consumer experience (Oct to Dec 2022)

At North Lakes Day Hospital we implement the highest standards in infection prevention and control including:

  • Hand hygiene
  • Use of Personal Protective equipment
  • Safe use of disposal consumable equipment
  • Reprocessing of medical equipment
  • Routine Cleaning

We have two staff members recruited to become Standard Auditors with the National Hand Hygiene Initiative (NHHI) run by the Australian Commission on Safety and Quality in Healthcare.

Further supporting our commitment to excellent infection prevention, North Lakes reported a 98% compliance rate in hand hygiene as of October and zero post-surgical infections for the last quarter.

Patient Outcomes - Post-surgical Infections
(Oct to Dec 2022)

Safety reporting systems are a very important aspect of ensuring patient safety at North Lakes. Detecting near misses and incidents enables us to improve practice and prevent any future adverse events. A near miss is an adverse event that has been intercepted and has not resulted in harm for example:

  • Slip or falls not resulting in injury
  • Medication error that has not resulted in harm (refer to Medication safety)
  • Pressure Injuries resulting in no harm

We are pleased to report no incidents of falls or pressure injuries at North Lakes for the period October to December 2022.

Incidents of Falls
(Oct to Dec 2022)

Pressure Injuries
(Oct to Dec 2022)

Medication errors can have an impact on patient outcomes and can cause harm. North Lakes Day Hospital medication safety systems are in place to prevent the occurrence of medical-related incidents. Staff are trained in the safe and appropriate use of medicines. 

Medication risks are described as errors in:

  • Prescribing
  • Administering and/or
  • Dispensing medication

Of the 968 patients treated at North Lakes Day Hospital from October to December 2022, there was one incident reported in Medication Safety.

Medication Safety (Oct to Dec 2022)

Surgical complication requiring the unplanned return to theatre within one month of a patient’s most recent discharge from hospital is classified as an Unexpected Return to Theatre. The return subjects the patient to repeated anaesthesia risks, which can be highly distressing and impact the patient and their family. Returning to the theatre generally occurs because the patient experiences one of the following:

  • Haemorrhage / bleeding
  • Wound reopening

The occurrence of unexpected return to theatre data from North Lakes Day Hospital has been collated and graphed for analysis.  The last quarter report shows there were no unexpected returns to theatre from October to December 2022.

Unexpected Returns to Theatre (Oct to Dec 2022)