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Patient Safety and Quality

Our Commitment to Patient Safety and Quality

Oxford Day Surgery is committed to providing the highest quality healthcare, with a core focus on each patient’s experience. Achieving the best outcomes for patients in a safe, caring and friendly environment is reflected in our day-to-day operations, corporate and clinical governance, values and workplace culture.

We are owned and operated by National healthcare provider, Montserrat Day Hospitals and utilise their robust Quality Management System (QMS) and framework to manage the care and services we provide.

The Montserrat Day Hospital 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.

At Oxford Day Surgery our Quality scorecard includes:

  • Patients’ experience and feedback
  • Hand hygiene compliance rates
  • Surgical site infections
  • Fall rates
  • Medication safety
  • Unplanned returns to theatre

At all times we uphold the National Safety and Quality Health Service Standards (NSQHS). Learn more about our approach to the National Standards below and how we utilise our QMS and framework as we strive to be leaders in the provision of quality healthcare.

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

At Oxford 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.

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

Oxford Day Surgery partners with select consumers and patients as this has proven beneficial in the planning, design, delivery, measurement and evaluation of our healthcare facility. We place great importance on these partnerships as they help to guarantee quality patient outcomes and safety standards, whilst also benefiting patients’ carers and families, our clinicians and more broadly the healthcare industry. Partnerships have a positive effect on service planning, evaluating and development at our Day Surgery, and these partnerships exist across three levels:

  1. The relationship between Oxford’s clinician and patient at the point of care; a relationship founded on our 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.

Oxford 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 Oxford 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, Oxford 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 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 including scripts to care for themselves once home.

Oxford Day Surgery provides continuous and collaborative care to patients in partnership with carers, families and all members of their healthcare team. Our hospital has integrated systems in place supporting our clinicians to deliver comprehensive, quality healthcare whilst mitigating and managing the 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. Oxford 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.

Oxford 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 Oxford 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 Oxford 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.

Oxford Day Surgery’s Patient Safety & Quality Management (QMS) Latest Quarterly Report

Oxford Day Surgery measures quality in many areas, by analysing and reporting on outcome and process measures, patient satisfaction and the hospital quality ranking.

Our core, quality principle is the continuous improvement of all processes and services supporting the care of patients. The Quality Management System (QMS) implemented across our hospital group, as previously defined allows us to deliver consistent and comprehensive care to our patients.

As part of the Montserrat Day Hospital group, Oxford Day Surgery monitors and reports on many quality measures including patient satisfaction surveys and the patient experience, infection prevention and control including hand hygiene compliance rates, patient incidents, medication safety, workforce training and compliance 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 highly-trained nurses and medical staff.

Oxford Day Surgery’s Quality Measures

  • Patients Experience- Feedback
  • Infection Prevention
  • Monitoring incidents
  • Medication safety
  • Return to theatres monitoring

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 Oxford 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 receive. At Oxford Day Surgery, patients are asked: “How likely are you to recommend our hospital to friends and family if they need 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 patient). 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, Oxford Day Surgery achieved a Net Promoter Score of 84. Some of the more detailed results from patient feedback during this period revealed:

  • 98% of surveyed patients expressed satisfaction with the quality of care received
  • 96% praised our staff’s communication
  • 98% felt safe whilst in our care

Net Promoter Score
(July to Sept 2024)

Net Promoter Score - 84

Quality of Care
(July to Sept 2024)

Staff Communication
(July to Sept 2024)

Felt Safe in Hospital
(July to Sept 2024)

Oxford 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 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.

Oxford 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, Oxford Day Surgery provided care to 853 patients. Through the diligent efforts of our doctors, staff, patients and visitors, we are proud to report zero post-surgical infections and a 95% hand hygiene compliance rate during this time.

Post-surgical Infections
(July to Sept 2024)

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. Oxford 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 853 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 Oxford Day Surgery we use a variety of methods to both prevent and treat pressure injuries, and our target is always zero injuries.

Patient Falls
(July to Sept 2024)

Pressure Injuries
(July to Sept 2024)

Safe medication management is important to us at Oxford 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 Oxford follow strict guidelines so 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 delighted to advise there were no medication errors at our hospital for the last reporting period.

Medication Safety (July to Sept 2024)

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 Oxford 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 853 patients, none of whom needed to return to theatre after surgery.

Unexpected Returns to Theatre
(July to Sept 2024)

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Oxford Day Surgery is a first-class accredited day hospital that is modern, purpose-built and conveniently located. Established in 2009 as a Mohs specialty hospital by a number of Australia’s leading Dermatologists accredited in Mohs Surgery, its facilities include:

  • 4 x theatres providing Mohs surgery, general dermatology and vasectomy procedures
  • Pathology collection and laboratory on-site
  • Onsite specialist consulting suites
  • Comfortable pre-operative and recovery lounge
  • Undercover off-street parking with lift access available
  • State-of-the-art sterilisation equipment and infection control standards

At Oxford Day Surgery we are proud to deliver the highest standard in clinical and nursing care to patients, families and clinicians through respect, integrity, innovation and compassion.

OUR FACILITIES

  • 4 theatres providing Mohs surgery, general dermatology and vasectomy procedures
  • Laboratory on site to provide a quick turnaround of results for Mohs patients
  • 10 chairs and 1 bed in a comfortable pre-operative and recovery lounge
  • Onsite specialist consulting suites
  • Onsite pathology collection
  • State-of-the-art sterilisation equipment and infection control standards
  • Undercover off-street parking below the facility with lift access available
  • Ample free public parking and a car park 80m away in Oxford Steet.  Public transport access is also convenient.

CONTACT US

Suite 4, First Floor
416-418 Oxford Street
(Cnr Scarborough Beach Road)
Mount Hawthorn WA 6016

P: 08 6147 2600
F: 08 6147 2699
E: reception@oxforddaysurgery.com.au

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