Patient Safety and Quality

Warringah Day Surgery’s Patient Safety & Quality Health Services Standards

Patient safety and the provision of high-quality healthcare at Warringah Day Surgery are reflected in the values, culture, corporate and clinical governance, and day-to-day operations of our hospital.

Owned and operated by reputable healthcare provider, Montserrat Day Hospitals, Warringah Day Surgery is committed to providing an individualised, patient-centred experience each and every time, ensuring excellent patient care and outcomes in a safe, caring and friendly environment. The Montserrat Day Hospital Group has a robust Quality Management System and framework that covers the care and services delivered at Warringah Day Surgery.

Our Quality Management System (QMS)

Our 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 strive to be leaders in the provision of healthcare, upholding the National Safety and Quality Health Service Standards. As a patient, these standards provide context around the high level of care you can expect to receive at our facility.

Warringah’s Approach to the Eight National Safety & Quality Health Service Standards

1. Clinical Governance

At Warringah Day Surgery, we take our responsibility to the community very seriously. We gather important data across all aspects of our hospital to continuously improve the safety, effectiveness and quality of our services. Delivering quality, patient-focused healthcare is our commitment and our management across all levels of the organisation use clinical governance systems to achieve, monitor and regularly review our safety and quality performance.

Everyone at Warringah Day Surgery – nurses, clinicians, management, the board of Directors and support staff have accountability to patients and the broader community for assuring the delivery of our healthcare is safe, effective, integrated, high quality and continuously improving.

2. Partnering with Consumers

Both consumers and patients partner with Warringah Day Surgery to assist in the planning, design, delivery, measurement and evaluation of our healthcare facility. These partnerships are very important as they help to guarantee quality patient outcomes and safety standards, whilst also benefiting patients’ carers and families, our clinicians and other healthcare providers. Partnerships have a positive effect on service planning, evaluating and development at Warringah. These partnerships refer to:

The relationship between clinician and patient at the point of care; a relationship founded on Warringah Day Surgery’s values of respect, integrity, collaboration, innovation and compassion.
Patients, carers, families and consumers involvement in planning, implementing and evaluating change at the department level at our facility.
Consumers or patients’ involvement in the governance, policy and planning of our healthcare service, focusing on key areas like patient safety, facility design, quality improvement, patient or family education, staff education and training, ethics and research. Partnerships with the broader community may also occur at this level.

3. Preventing & Controlling Infections

Warringah Day Surgery 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 adopt a precautionary, proactive approach whilst upholding the highest standards in hygiene and cleanliness. We have high compliance rates of hand hygiene, and a well-maintained facility that is optimised for patient flow. Our approach to preventing, controlling and responding to infections is well supported by the policies, processes and systems we have in place, creating a safe environment for patients, visitors and members of our workforce.

4. Medication Safety

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 Warringah Day Surgery. 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, Warringah Day Surgery 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 any 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 to care for themselves once home.

5. Comprehensive Care

Providing continuous and collaborative care to patients in partnership with carers, families and all members of the healthcare team is of paramount importance at Warringah Day Surgery. Our hospital has integrated systems in place supporting our clinicians to deliver comprehensive, quality healthcare whilst mitigating and managing risk of harm.

All clinicians at our Day Surgery 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 harm from occurring. Safely managing transitions between episodes of care, and ensuring a continuum of comprehensive care are standards our clinicians abide by.

6. Communicating for Safety

One of the best ways we support coordinated and safe patient care as well as visitor and workforce safety is through effective 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. Warringah 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.

7. Blood Management

Warringah Day Surgery manages blood on an infrequent basis given the nature of our surgery and specialities. When required, we use 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.

8. Recognising & Responding to Acute Deterioration

Clinicians, nurses and support staff at Warringah Day Surgery 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 Warringah Day Surgery 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.

Warringah Day Surgery’s Patient Safety & Quality Management System (QMS) Quarterly Report: July to September 2024

As part of the Montserrat Day Hospital group, Warringah 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.

Warringah Day Surgery’s Quality Measures

Patient Satisfaction & Experience

We never stop caring about patient care. That’s why we continually monitor and assess everything we do, so we can improve the quality of care we provide. Patient feedback plays a crucial role in maintaining and enhancing the quality of care provided at Warringah Day Surgery. By actively listening to our patients, we gain valuable insights into their experiences, allowing us to make informed decisions about how to improve our services. Our quality outcomes are reviewed by our Medical Advisory Committee (MAC) before being made available for consumer feedback.

We encourage patients to confidentially share their thoughts through a post-operative survey sent via email. This continuous process of collecting and reviewing feedback ensures that we remain responsive to the needs and expectations of our patients, aligning with the National Safety and Quality Health Service (NSQHS) Standards.

One of the key metrics we use to gauge patient satisfaction is the Net Promoter Score (NPS).

The NPS is a simple way to measure how happy our patients are with the care they received. At Warringah Day Surgery, patients are asked: “How likely are you to recommend our hospital to friends and family if they needed similar care or treatment?”

Patients rate this on a scale from 0 to 10, with:

10 being ‘extremely likely’ and
0 being ‘not likely at all’

Scores of 9 or 10 are considered “promoters” (very happy patients), 7 or 8 are “passives” (neutral), and anything below 7 is a “detractor” (unhappy patients). The NPS is calculated by subtracting the percentage of detractors from the percentage of promoters.

According to global NPS standards, an NPS score over 70 is considered very high and shows the service is world-class. From July to September 2024, Warringah Day Surgery achieved a Net Promoter Score of 88.

Net Promoter Score (Jul-Sept 2024)

Net Promoter Score - 88

Some of the more detailed results from patient feedback during this period revealed:

99% of surveyed patients expressed satisfaction with the quality of care received
100% praised our staff’s communication
98% felt safe whilst in our care

Quality of Care
(Jul-Sept 2024)

Staff Communicated Well
(Jul-Sept 2024)

Felt Safe in Hospital
(Jul-Sept 2024)

Infection Prevention

Warringah Day Surgery follows strict infection control procedures. Our staff take every precaution to prevent infections and our antibiotic usage is monitored against best practice. As most patients are discharged the same day, we try to get feedback from your specialist or GP if any infections occur. We encourage you to contact us directly if you have any concerns regarding this.

Warringah Day Surgery employs a variety of strategies to prevent infections. These include:

auditing how often and how well staff wash their hands using soap and water or hand sanitiser
using gloves and specialised sterile equipment
using specialised disinfectants when cleaning facilities
following national guidelines for high-level disinfection and sterilisation processes
placing hand sanitiser dispensers in public areas throughout our hospital so that they are readily accessible to staff, patients and visitors.

During the period from July to September 2024, Warringah Day Surgery provided care to 687 patients. Through the diligent efforts of our doctors, staff, patients and visitors, we are proud to report zero post-surgical infections during this time and a 96.5% compliance rate in hand hygiene.

Patient Outcomes
Post-surgical Infections
(Jul-Sept 2024)

Monitoring incidents & near misses

Patient Falls

Patient falls are a leading cause of injury in hospitals and can extend or complicate a patient’s stay. Falls can occur when patients are weakened by illness, surgery, or accidents. Warringah Day Surgery has robust measures in place to create a safe environment where the likelihood of patient falls is minimised. From July to September 2024, we cared for 687 patients, none of whom experienced a fall whilst in our care.

Pressure Injuries

Also known as bedsores, pressure injuries occur when prolonged pressure damages the skin, ranging from redness to ulcers. Patients who are elderly, bedridden, have mobility issues, or chronic conditions like diabetes are more vulnerable. Pressure injuries often develop on hips, heels, tailbones, or other bony areas. At Warringah Day Surgery, we use a variety of methods to both prevent and treat pressure injuries, and none of our patients sustained an injury from July to September 2024.

Patient Falls
(Jul-Sept 2024)

Pressure Injuries
(Jul-Sept 2024)

Medication Safety

Safe medication management is important to us at Warringah Day Surgery. There are many systems in use throughout the hospital to support and promote safety in supplying and administering medications and monitoring their effects.

Staff at Warringah Day Surgery follow strict guidelines to ensure that all medications are administered appropriately and accurately. Should errors in medication administration occur, they are captured in our hospital’s incident reporting system and investigated.

We are pleased to confirm there were zero medication errors at our hospital for the last reporting period.

Medication Safety (Jul-Sept 2024)

Unexpected Return to Theatre

An unexpected return to the operating theatre is a serious event that may occur if complications arise after surgery. This can happen for various reasons, including infections, bleeding, or other unforeseen issues. At Warringah Day Surgery, we have thorough processes in place to prevent these occurrences and deliver the highest standard of care for our patients. From July to September 2024, we cared for 687 patients, none of whom needed to return to theatre after surgery.

Patient Safety and Quality

Warringah Day Surgery’s Patient Safety & Quality Health Services Standards

Warringah’s Approach to the Eight National Safety & Quality Health Service Standards

Warringah Day Surgery’s Patient Safety & Quality Management System (QMS) Quarterly Report: July to September 2024

Warringah Day Surgery’s Quality Measures

Net Promoter Score (Jul-Sept 2024)

Quality of Care
(Jul-Sept 2024)

Staff Communicated Well
(Jul-Sept 2024)

Felt Safe in Hospital
(Jul-Sept 2024)

Patient Outcomes
Post-surgical Infections
(Jul-Sept 2024)

Patient Falls
(Jul-Sept 2024)

Pressure Injuries
(Jul-Sept 2024)

Medication Safety (Jul-Sept 2024)

Unexpected Returns to Theatre
(Jul-Sept 2024)

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