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Patient Safety and Quality

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

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.

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:

  1. 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.
  2. Patients, carers, families and consumers involvement in planning, implementing and evaluating change at the department level at our facility.
  3. 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.

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.

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. Information relating to a patient’s allergies and adverse drug reactions is disclosed by the patient in our Health Assessment form before their admission.

We partner with community pharmacy providers to ensure our patients get the right medication and education, with all medications dispensed as part of their hospital stay. 

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.

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.

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.

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 2021

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 feedback provides valuable information and not only ensures that patients’ voices are heard, but by examining patients’ feedback it gives direct insight into the quality of care and patient satisfaction.  This aids in maintaining and improving the standard of care received at Warringah Day Surgery.  We encourage patients to provide feedback using the feedback form provided or by visiting our website.

Consumer satisfaction data from Warringah Day Surgery has been collated and graphed for analysis.  The last quarter (July to September 2021) reports a very high level of satisfaction and consumer experience.

Consumer Satisfaction (July - Sept 2021)

Consumer Satisfaction 97.5%

Consumer experience (July - Sep 2021)
[TOTAL PATIENTS - 741]

Across the Montserrat Day Hospital group, we incorporate high standard precautions for infection prevention and control including:

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

Warringah Day Surgery is currently reporting 100% compliance (July to September 2021) in hand hygiene with zero reported post-surgical infections for the July to September 2021 period. This is an excellent result highlighting the excellent clinical care provided in a safe environment.

Patient Outcomes - Post-surgical Infections (July to Sept 2021)

Safety reporting systems are a very important step for improving patient safety.  Therefore, detecting near misses and incidents enables Warringah Day Surgery 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

The occurrence of incidents data at Warringah Day Surgery has been collated and graphed for analysis.  The last quarter for July to September 2021 reported a zero-percentage meaning there were no incidents or near misses.

Incidents Falls
(July to Sept 2021)
[TOTAL PATIENTS - 741]

Pressure Injuries
(July to Sept 2021)
[TOTAL PATIENTS - 741]

Medication errors can have an impact on patient outcomes and can cause harm. Warringah Day Surgery’s 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
  • Dispensing

From a total of 741 patient episodes at Warringah Day Surgery for the period July to September 2021, there was only one near miss that occurred resulting in a very low incidence rate of 0.13 percent for Medication safety.

Medication Safety (July - Sep 2021)
[TOTAL PATIENTS - 741]

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, 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 Warringah Day Surgery has been collated and graphed for analysis.  The last quarter report shows zero occurrences as a percentage during the period July to September 2021.

Unexpected Returns to Theatres (July to Sept 2021)