Lakeview Private Hospital Patient Safety & Quality Management

1. Summary & Objectives
1.1. Business Review Report – September 2017

2. Clinical Outcomes
2.1. Clinical Indicator Results

3. Infection Control
3.1. Accident, Infection and Incident Reports

4. Consumer Involvement / Patient Satisfaction
4.1. Consumer Focus Group Terms of Reference

5. Lakeview Private Hospital Rehabilitation Report
5.1. Rehabilitation data

1. Summary & Objectives

Lakeview Private Hospital is committed to ensuring that the highest possible levels of patient safety and quality care are maintained. To achieve this, we have developed an ongoing comprehensive “Patient Safety & Quality Management” process that constantly addresses and monitors patient safety, clinical outcomes and infection control.
In addition to helping ensure that these high levels are maintained, the process also sees us regularly involving our patients and consumers and sourcing their feedback to ensure we maintain a level of patient satisfaction that we believe is second to none.

1.1 Business Review Report

The National Safety and Quality Health Service (NSQHS) Standards were developed by the Australian Commission on Safety and Quality in Healthcare with the Australian Government, state and territory partners, consumers and the private sector. The primary aim of the NSQHS Standards is to protect the public from harm and improve the quality of health care. They describe the level of care that should be provided by health service organisations and the systems that are needed to deliver such care. Lakeview Private Hospital and other health service organisations are subsequently subject to an annual accreditation review to ensure they comply to National Standards.

Lakeview Private Hospital Business Review – September 2017: The last accreditation review of Lakeview Private Hospital took place in September 2017 over a period of 2 days. The surveyors provided very positive feedback and made particular mention of the excellent work carried out by the Lakeview Private Hospital Quality Manager, Sally Holmes. Comments made at the closing meeting by the assessors included the following:

  • Staff “so open, so enthusiastic”
  • Gaps between quality managers, but the gaps are being filled.
  • Education have clearly worked very hard and have done great work
  • Administration Manager has amazing structure going on.
  • Philosophy ‘Patients First’ is evident through talking to all the staff and the managers truly believe in it.
  • 100% satisfactorily met all core and developmental items.
  • It was a complete pleasure to appraise Lakeview Private Hospital, it’s an amazing Hospital.

To request a copy of the Lakeview Private Hospital Business Review Report, please click below.

The next business review was due late 2021 (every three years) however, due to the COVID-19 pandemic the 2021 Business Review has been deferred until 28th of March 2022.

2. Clinical Outcomes

Lakeview Private Hospital processes have been designed to address all clinical outcomes, not only with regards to the actual health of our patients but to ensure that they have the best possible hospital experience. We constantly review our clinical outcomes and establish standards that we monitor and improve as and when necessary. Every health facility in Australia has to submit data to the ACHS (The Australian Council on Healthcare Standards) an independent, not-for-profit organisation dedicated to improving quality in health care. The Council represents governments, consumers and peak health bodies from throughout Australia and is Australia’s leading health care assessment and accreditation provider. ACHS works with health care professionals, consumers, and government and industry stakeholders to develop and continually review health standards.

The ACHS Accreditation system is considered to comprise five key elements:

  • Governance or stewardship function
  • A standards-setting process
  • A process of external evaluation of compliance against those standards
  • A remediation or improvement process following the review
  • Promotion of continuous quality improvement.

The Accreditation system enables ACHS to benchmark health care organisations in Australia.

Lakeview Private Hospital – ACHS General Comparison Report – First Half 2021: The last Comparison Report for Lakeview Private Hospital was compiled and delivered was the first half of 2021. Lakeview Private Hospital excelled in a number of areas. These included but were not limited to the following:

Anaesthesia & Perioperative Care Version 7
Pre-anaesthesia consultation completed by anaesthetist (H). Lakeview Private Hospital rate: 99.967%.
Aggregate Industry rate: 95.690%.
Higher is better.
Documented patient handover operating suite to recovery area (H). Lakeview Private Hospital rate: 99.875%.
Aggregate Industry rate: 99.898%.
Higher is better.
Day Patient Version 6
Cancellation of procedure after arrival due to administrative/organisational reasons (L). Lakeview Private Hospital rate: 0.124%.
Aggregate Industry rate: 0.616%.
Lower is better.
Unplanned transfer or admission related to ongoing management (L). Lakeview Private Hospital rate: 0.196%.
Aggregate Industry rate: 0.546%.
Lower is better.
Departure without an escort (L). Lakeview Private Hospital rate: 0.031%.
Aggregate Industry rate: 0.477%.
Lower is better.
Hospital-Wide Version 13
Inpatients who develop >=1 pressure injuries (L). Lakeview Private Hospital rate: 0.00%.
Aggregate Industry rate: 0.19%.
Lower is better.
Inpatient falls Lakeview Private Hospital rate: 0.145%.
Aggregate Industry rate: 0.338%.
Lower is better.
Infection Control Version 5
Superficial SSI – hip prosthesis procedure (L) Lakeview Private Hospital rate: 2.273%.
Aggregate Industry rate: 0.534%.
Lower is better.
Superficial knee prosthesis procedure (L). Lakeview Private Hospital rate: 0.00%.
Aggregate Industry rate: 0.242%.
Lower is better.

To request the full ACHS General Comparison Report for Lakeview Private Hospital, please click below.

3. Infection Control

In addition to adhering to the procedures and monitoring under NSW Health Guidelines, Clinical Excellence Commission  COVID-19 Infection Prevention and Control Manual and Australian Government NHMRC guidelines (2019), Lakeview Private Hospital’s own “Patient Safety & Quality Management” processes enable us to self-monitor and ensure that we minimise the risk of spreading infections and reduce the occurrence of infectious diseases.

3.1 Accident, Infection and Incident Reports

The Lakeview Private Hospital Quality Management team compile a detailed report on accidents, incidents and infections on a monthly basis with a more detailed report every six months. The results of our most recent six-monthly report detailed an extremely low level of incidents and infections.

Lakeview Private Hospital Accident, Incidents & Infections Report – January to December 2021
Total bed days = 12,849
Total incidents = 175
Percentage: 1.36% of bed days
Total infections = 20
Ie: 0.1% including community acquired infectons
6 Nosocomial (Hospital Acquired) Infections

To request the Lakeview Private Hospital Accidents, Incidents & Infections Report 1st half 2020, please click below.

To request a sample of the monthly Incident Analysis & Quality Summary Report, please click below.

4. Consumer Involvement / Patient Satisfaction

Lakeview Private Hospital has put together a Consumer Focus Group to involve consumers and/or carers in the review of the safety and quality of services at Lakeview Private Hospital. Partnering with consumers enables us to listen and gain invaluable feedback using consumer knowledge, skills and experience in a systematic way in order for us to deliver better health care.

4.1 Consumer Focus Group Terms of Reference

The Consumer Focus Group provides advice and recommendations to the General Manager, Director of Nursing and Continuous Quality Improvement Committee on any matters relating to strategic and operational planning, quality and safety, patient information publications, patient feedback, design & redesign of health services. This in turn is also reported to the Medical Advisory Committee (MAC) with the minutes forwarded to the Board.

This group also analyses the organizational safety and quality performance and the planning and implementation of quality improvements and participates in the evaluation of patient feedback data. This is to ensure the Foundation is complying with the National Safety and Quality Health Service Standards (Version 2).

To request the full Lakeview Private Hospital Consumer Focus Group Terms of Reference, please click below.

5. Lakeview Private Hospital Rehabilitation Report

Lakeview Private Hospital is not only committed to patient safety and delivering quality services at our facility but we also take great pride in ensuring our patients have the best rehabilitation facilities available. As such, Lakeview Private Hospital boasts a purpose-built state-of-the-art rehabilitation facility which offers orthopaedic and reconditioning inpatient and outpatient services with the very latest in equipment, a hydrotherapy pool and spa, and the combined expertise of the best of medical professionals — all set in a peaceful, modern environment.

Our highly skilled, professional and compassionate staff have been hand-picked to work at Lakeview Private Hospital Rehabilitation Unit. We have a high staff to patient ratio and are committed to delivering the best possible care. Our multidisciplinary team work closely with each patient and their family to develop programs that are tailored specifically to their needs, based on mutually agreed and meaningful goals.
From rehabilitation physicians, nurses, physiotherapists, and occupational therapists to social workers, discharge planners, dieticians, speech pathologists and clinical psychologists, the Lakeview Private Hospital Rehabilitation Unit team provides comprehensive patient-focused care. Outpatient services, lifestyle and wellness programs, and group therapy sessions are just some of the ways Lakeview Private Hospital Rehabilitation Unit provides patients with continuity of care and ongoing support.
We believe it all adds up to a deep commitment to helping our patients recover quickly and live their lives to the fullest.

5.1 Rehabilitation data

Our commitment to the rehabilitation of our patients is reflected by our stringent self-monitoring processes. Monthly reports are compiled to monitor key aspects of our patients rehabilitation journey to ensure we maintain the highest levels of care and best possible outcomes.

Areas we monitor include the following. These areas enable us to ensure all staff and referral partners are kept informed and educated as to processes:

  • Patients admitted
  • Source of admissions
  • Bed occupancy levels
  • Average length of stays
  • Referrals from external hospitals and doctors

To request the full Lakeview Private Hospital Rehabilitation Report on the above, please click below.