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Wolper achieves outstanding results in accreditation audit

The National Safety and Quality Health Service (NSQHS) Standards were developed by the Australian Commission on Safety and Quality and Health Care to drive the implementation of safety and quality systems and improve the quality of health care in Australia. The 10 NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health service organisations.

Wolper Jewish Hospital has recently undergone full accreditation against all 10 NSQHS Standards.

Independent auditors spent two days at the Hospital reviewing its policies, procedures and practises and have recommended ongoing certification with 26 ‘met with merit’ findings, which are reported back to the Australian Commission on Safety and Quality on Healthcare.

John Tucker, Wolper Chief Executive Officer commented after the auditors’ findings were delivered to Wolper management, “This is such an excellent result as it is well known in the industry that the Commission is granting fewer ‘with merits’ to ensure that each endorsement is truly exceptional and above expectations.

The auditors recommended ‘met with merit’ findings in the general areas of governance, education, infection control, antimicrobial stewardship, medication management as well as consumer and community partnership.

The merits relate to the following actions taken and rigorously maintained by Wolper management and staff:


  • An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and protocols.
  • Patient safety and quality of care is always considered in business decision making.
  • Regular reports on safety and quality performance data are regularly monitored by management.
  • Action is taken to improve the safety and quality of patient care.
  • An organisation-wide quality management system is used and regularly monitored.
  • Actions are taken to maximise patient quality of care.
  • The workforce has access to ongoing safety and quality education and training.

Partnering with Consumers

  • Consumers and carers are involved in the governance of the health service organisation.
  • Governance partnerships are reflective of the diverse range of backgrounds in the population served by the Hospital.
  • Mechanisms are in place for engaging consumers and carers in the strategic and operational planning for the organisation.
  • Consumers and carers are involved in decision making about safety and quality.
  • Wolper provides orientation and ongoing training for consumers and carers to enable them to fulfil their partnership role.
  • Consumers and carers provide feedback on patient information publications prepared by the Hospital (for distribution to patients).
  • Action is taken to incorporate consumer and carers’ feedback into publications prepared for distribution to patients.
  • Consumers and carers participate in the design and redesign of health services.
  • Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care.
  • Consumers and carers are involved in training the clinical workforce.
  • The community and consumers are provided with information that is meaningful and relevant on the organisation’s safety and quality performance.
  • Consumers and carers participate in the evaluation of patient feedback data.

Preventing and Controlling Healthcare Associated Infections

  • An antimicrobial stewardship program is in place.
  • Monitoring of antimicrobial usage and resistance is undertaken.
  • Action is taken to improve the effectiveness of antimicrobial stewardship.
  • Policies, procedures and protocols for environmental cleaning that address the principles of infection prevention and control are implemented.

Medication Safety

  • A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines.
  • A current and comprehensive list of medicines is provided to the patient and/or carer when concluding an episode of care.
  • Clinical staff provides patients with their medicine information, including medical treatment options, benefits and associated risks.

During their presentation, the auditors specifically praised Dr Ben Basger’s medication review service and Wolper’s Community Partnership Committee, calling it an “enormous driver of extraordinary levels of engagement”. The auditors also noted that “patients obviously feel safe and rightly so…” and that “the close and effective integration of nursing and physiotherapy under your in-house model of care was apparent, unlike other facilities that we visit…”.

Daniel Goulburn, Wolper Jewish Hospital President commented, “I express my appreciation to the entire management team led by John Tucker and Tina Boger, Director of Clinical Services, as well as our quality advisors and all staff for the considerable planning, preparation, implementation and effort that has gone into achieving this extraordinary result. They have done us proud.”

The next interim review against Standards 1-3 will be in September 2018 and the next full review will be in March 2020.

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