Consumer Safety and Quality Performance Report August 2018

CLINICAL GOVERNANCE
At its June 2018 meeting, the Board of Directors of Wolper Jewish Hospital approved an updated set of Hospital By-laws that govern the appointment of Visiting Medical and other clinical health practitioners to Wolper Jewish Hospital. Last updated in 2013, these By-laws continue to ensure the right clinicians are providing the right services to our patients.

Wolper belongs to a Private Hospital Benchmarking Group. This enables the Hospital to compare audit results with other similar private hospitals to help us improve our service. We recently undertook a Clinical Processes Review Audit.

This graph shows Wolper’s compliance benchmarked against the Private Hospital Group over 4 key areas – Comprehensive Care, Communicating for Safety, Blood Management and Recognising and Responding to Acute Deterioration. Comprehensive Care and Communicating for Safety are new standards forming part of the Second Edition of the National Safety and Quality Health Service (NSQHS) Standards for implementation in January 2019. Wolper’s overall compliance for this Audit was 97% and the Group’s overall compliance was 94%.

The Benchmarking Audit Results are reviewed regularly by the Quality & Risk and Clinical Care Committees then reported to the Board and Medical Executive Committee via Quarterly Safety and Quality Reports.

INFECTION PREVENTION AND CONTROL
As part of our Antimicrobial Stewardship program, the hospital pharmacist completed an antibiotic audit in May. In some cases the duration and frequency of antibiotic treatment exceeded the guidelines and was reported to the Medical Executive committee and the Board and appropriate action taken.
6 additional Hand Hygiene auditors were trained in July this year to help monitor infection control through effective hand hygiene practices.
A new range of cleaning products was introduced this year with specialised training provided for cleaning staff as well as improved ongoing education and monthly Cleaning Audit Reports to improve infection prevention and control.

ACCREDITATION
Our surveillance audit for National Safety and Quality Health Service Standards (NSQHSS) Standards 1-3 takes place next month. Standard 1- Governance, 2 – Partnering with Consumers and 3 – Preventing and Controlling Healthcare Associated Infections. Our 3 yearly reaccreditation audit to the new Edition is scheduled for November 2019.