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Clinical Governance scorecard - January-June 2016

Reporting period: 
1 January 2016 to 30 June 2016

Clinical Governance' is a series of systems designed to reduce harm to patients.

We set standards aligned with the National Safety and Quality Health Service Standards (NSQHS) for how care should be provided and we check how well we meet these standards by measuring our performance as well as feeding back this information to staff to help them keep improving.

Key Performance Indicators

Never Events

Average MSH score
0
Since last quarter
Improving
Best performing hospital/services
0
Most improved hospital/service
0
Our target
0

What we measure

The number of 'never events' that have occurred during the reporting period. These are events that are avoidable and should not occur. For example, surgery on the wrong side of the body.

Hospital Standardised Mortality Ratio

Average MSH score
61.2
Since last quarter
Declining
Best performing hospital/services
48
Most improved hospital/service
64
Our target
≤ 100

What we measure

The Hospital Standardised Mortality Ratio is a tool to help monitor and identify opportunities for improving patient care. This is an overall death ratio as compared to other similar hospitals.

In-hospital mortality: acute myocardial infarction

Average MSH score
WCL
Since last quarter
Improving
Best performing hospital/services
WCL
Most improved hospital/service
WCL
Our target
WCL

What we measure

We track the death rate of heart attacks for people admitted to our hospitals.

Key to results:

  • WCL - within expected limits
  • LL1/2/3 - lower level

In-hospital mortality: stroke

Average MSH score
WCL
Since last quarter
Improving
Best performing hospital/services
WCL
Most improved hospital/service
WCL
Our target
WCL

What we measure

We track the death rate of strokes for people admitted to our hospitals.

Key to results:

  • WCL - within expected limits
  • LL1/2/3 - lower level

In-hospital mortality: neck of femur fracture

Average MSH score
WCL
Since last quarter
No change
Best performing hospital/services
WCL
Most improved hospital/service
WCL
Our target
WCL

What we measure

We track the death rate of broken hips (NOF - neck of femur) for people admitted to our hospitals.

Key to results:

  • WCL - within expected limits
  • LL1/2/3 - lower level

In-hospital mortality: pneumonia

Average MSH score
WCL
Since last quarter
Improving
Best performing hospital/services
WCL
Most improved hospital/service
WCL
Our target
WCL

What we measure

We track the death rate of pneumonia for people admitted to our hospitals.

Key to results:

  • WCL - within expected limits
  • LL1/2/3 - lower level

Acute stroke care in recognised stroke unit

Average MSH score
84.25%
Since last quarter
Declining
Best performing hospital/services
90%
Most improved hospital/service
90%
Our target
≥ 90%

What we measure

We track the number of stroke patients who are cared for in a specialised unit.

Patients with acute coronary syndrome referred to the Cardiac Rehabilitation program

Average MSH score
33.25%
Since last quarter
No change
Best performing hospital/services
61%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We track the number of cardiac patients who are referred to a specialised cardiac rehabilitation program.

3rd and 4th degree perineal tear (primigravida)

Average MSH score
2.37%
Since last quarter
No change
Best performing hospital/services
0%
Most improved hospital/service
N/A
Our target
≤ 5%

What we measure

We track the number of women who suffer a serious perineal during childbirth.

Number of neck of femur fractures to operating theatre within 2 days of admission

Average MSH score
93.33%
Since last quarter
Improving
Best performing hospital/services
94%
Most improved hospital/service
94%
Our target
≥ 90%

What we measure

We track the number of patients with broken hips who progress to the operating theatre within two days of admission. People with broken hips do better the quicker we surgically repair their hips.

NSQHS 1: Governance for Safety and Quality

Relative Stay Index

Average MSH score
81.25%
Since last quarter
Declining
Best performing hospital/services
68%
Most improved hospital/service
90%
Our target
≤ 90%

What we measure

We measure how long patients stay in hospital, taking into account their disease or condition. Unnecessary longer stays in hospital increase the risk to patients.

Complaints resolved within 35 days

Average MSH score
94.33%
Since last quarter
Declining
Best performing hospital/services
97%
Most improved hospital/service
96%
Our target
≥ 90%

What we measure

We measure the number of complaints resolved within 35 days. This ensures we maintain a good relationship with our customers and that we are responsive to any complaints.

Deaths reviewed by 3 tier process

Average MSH score
97.83%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
95%
Our target
≥ 90%

What we measure

We measure the number of deaths fully reviewed by our three tier process. Reviewing deaths allows us to see if there are any learnings for us to assist in improving care.

Medical credentialing compliance

Average MSH score
100%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
100%

What we measure

We audit the number of senior doctors who have had their medical credentials (qualifications) assessed.

Medical Specialties with current Senior Medical Performance Review

Average MSH score
59.33%
Since last quarter
Declining
Best performing hospital/services
89%
Most improved hospital/service
89%
Our target
≥ 90%

What we measure

We measure the number of Senior Medical Performance Reviews (SMPR) completed. The SMPR is a an evaluation and feedback tool for senior doctors, which helps them continue to improve their professional practice.

NSQHS 2: Partnering with Consumers

Patient satisfied with Nurses meeting most important expectations

Average MSH score
95%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We compare ourselves with other hospitals and health services throughout Australia on how patients view their nursing care.

Patient satisfaction with Doctors

Average MSH score
91.8%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We compare ourselves with other hospitals and health services throughout Australia on how patients view their medical care.

Patient satisfaction with Allied Health Professionals

Average MSH score
95.8%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We compare ourselves with other hospitals and health services throughout Australia on how patients view their allied health care.

Patient Satisfaction with Overall Quality

Average MSH score
93.8%
Since last quarter
No change
Best performing hospital/services
97%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We compare ourselves with other hospitals and health services throughout Australia on how patients view their overall care.

Patient agreement that staff were welcoming

Average MSH score
90%
Since last quarter
No change
Best performing hospital/services
90%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We compare ourselves with other hospitals and health services throughout Australia on how welcoming our staff are in outpatient clinics and wards.

Smoking Cessation pathway completed

Average MSH score
70.67%
Since last quarter
No change
Best performing hospital/services
89%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We track the number of patients who identify as smokers and who are offered tools to assist with quitting. Quitting smoking reduces the risk of complications and re-admission to hospital.

NSQHS 3: Preventing and Controlling Healthcare Associated Infections

Hand hygiene compliance - Medical Practitioner

Average MSH score
66.8%
Since last quarter
Improving
Best performing hospital/services
92%
Most improved hospital/service
76%
Our target
≥ 90%

What we measure

We audit the rates of hand washing by medical staff. Hand washing has been proven to help prevent the spread of infection.

Hand Hygiene compliance - Nurse

Average MSH score
84.2%
Since last quarter
Improving
Best performing hospital/services
92%
Most improved hospital/service
74%
Our target
≥ 90%

What we measure

We audit the rates of hand washing by nursing staff. Hand washing has been proven to help prevent the spread of infection.

Hand Hygiene compliance - Allied Health

Average MSH score
76.4%
Since last quarter
No change
Best performing hospital/services
84%
Most improved hospital/service
84%
Our target
≥ 90%

What we measure

We audit the rates of hand washing by allied health staff. Hand washing has been proven to help prevent the spread of infection.

Surgical antibiotic prophylaxis

Average MSH score
97.5%
Since last quarter
Declining
Best performing hospital/services
100%
Most improved hospital/service
97%
Our target
≥ 90%

What we measure

We check to make sure we give antibiotics as required to help prevent infections in people who have an operation.

Healthcare-associated Staph Aureus bacteraemia

Average MSH score
0.39
Since last quarter
Declining
Best performing hospital/services
0
Most improved hospital/service
0
Our target
< 2.0

What we measure

We measure the number of Staph Aureus bacteraemia infections during the reporting period. This is an infection that gets into the patient's blood and is often avoidable.

NSQHS 4: Medication Safety

Weekend pharmacist medication reconciliation

Average MSH score
46.67%
Since last quarter
Improving
Best performing hospital/services
85%
Most improved hospital/service
85%
Our target
≥ 90%

What we measure

Pharmacists are the professionals who make sure that we keep track of all of our patients' medications. We need to increase the rate at which we do this on the weekend.

Electronic medication discharge summaries

Average MSH score
96%
Since last quarter
Declining
Best performing hospital/services
77.75%
Most improved hospital/service
96%
Our target
≥ 90%

What we measure

We track the number of patients whose medications have been checked and recorded by a pharmacist for accuracy and completeness when they leave hospital.

Appropriate venous thromboembolism (VTE) prophylaxis rate

Average MSH score
85.5%
Since last quarter
Improving
Best performing hospital/services
93%
Most improved hospital/service
91%
Our target
≥ 90%

What we measure

Venous thromboembolism (VTE) is a disease where people get clots in their legs and lungs. Being in hospital increases the risk of VTE so we measure the steps we are taking to reduce the risk.

NSQHS 5: Patient Identification and Procedure Matching

Identification of patients prior to care / treatment

Average MSH score
93.2%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
98%
Our target
≥ 90%

What we measure

We track our idenfication rates to make sure we don't get patients mixed up and give the wrong care to the wrong patient.

Observational compliance with surgical safety checklist

Average MSH score
89.2%
Since last quarter
Declining
Best performing hospital/services
1005
Most improved hospital/service
100%
Our target
≥ 90%

What we measure

We measure the rates of completing the 'surgical safety checklist'. This is a checklist that is used around the world in operating theatres to help make sure staff remember to do certain tasks and to help with team communication.

NSQHS 6: Clinical Handover

Discharge Summaries completed within 48hrs

Average MSH score
55.17%
Since last quarter
No change
Best performing hospital/services
65%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

Discharge summaries are the main documents used to communicate a patient's care plan to their GP or post-hospital health care team. We track the number of discharge summaries completed within 48 hours of the patient's discharge from hospital.

NSQHS 7: Blood and Blood Products

Single unit red cell transfusion episodes

Average MSH score
38%
Since last quarter
Improving
Best performing hospital/services
40%
Most improved hospital/service
38%
Our target
≥ 20%

What we measure

If one unit of blood adequately improved the symptoms after a transfusion, then no further transfusion should occur. We measure this to help reduce the number of unnecessary transfusions.

NSQHS 8: Preventing and Managing Pressure Injuries

Hospital acquired pressure ulcer prevalence

Average MSH score
5.3%
Since last quarter
Declining
Best performing hospital/services
5.3%
Most improved hospital/service
N/A
Our target
≤ 10%

What we measure

Pressure injuries occur when pressure is applied to an area of skin for an extended period of time. This can occur when a patient doesn't move in their hospital bed. We track the rates of pressure injuries in our hospitals.

Skin inspection within 8 hours of admission

Average MSH score
86.67%
Since last quarter
No change
Best performing hospital/services
97%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

Pressure injuries occur when pressure is applied to an area of skin for an extended period of time. This can occur when a patient doesn't move in their hospital bed. We track the rates of patients who have their skin checked within 8 hours of being admitted to hospital.

Patients with weight recorded on admission

Average MSH score
90.67%
Since last quarter
Improving
Best performing hospital/services
91%
Most improved hospital/service
83%
Our target
≥ 90%

What we measure

We track the rates of patients who have their weight recorded when they are admitted to hospital. A person's weight is needed for a number of matters while they are in hospital.

Patients at risk of malnutrition with a nutrition care plan

Average MSH score
65.5%
Since last quarter
Declining
Best performing hospital/services
72%
Most improved hospital/service
73%
Our target
≥ 90%

What we measure

We measure the number of patients at risk of malnutrition due to their illness who have had a nutrition care plan completed.

NSQHS 9: Recognising & Responding to Clinical Deterioration

First year Principal House Officer/Registrar trained in Advanced Life Support

Average MSH score
88.5%
Since last quarter
Declining
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

Advanced Life Support (ALS) is a set of advanced life-saving protocols and skills that are used in a medical emergency to support the person's circulation and provide an open airway. We track the number of doctors who have completed ALS training.

Patients meeting 'medical emergency' criteria care are escalated to the appropriate team

Average MSH score
86%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We track the number of patients meeting the criteria for a 'medical emergency' who are escalated to a specialised Medical Emergency Team (MET) or Rapid Response Team (RRT) within the hospital.

NSQHS 10: Falls Prevention

Falls risk assessment completed

Average MSH score
84.5%
Since last quarter
Improving
Best performing hospital/services
85%
Most improved hospital/service
83%
Our target
≥ 90%

What we measure

We track the number of falls risk assessments completed for patients. This assesses the risk of a person falling while they are in hospital so that we can put preventative measures in place.

Patients requiring and have their mobility aid within reach

Average MSH score
10%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
N/A
Our target
≥ 90%

What we measure

We track the rates of patients with mobility issues and make sure their mobility aid (e.g. walking stick) is within reach of their hospital bed.

Mental Health Measure

Seclusion event per 1000 bed days (Adult)

Average MSH score
4.7%
Our target
≤ 10%

Seclusion event per 1000 bed days (Adolescent)

Average MSH score
6.3%
Our target
≤ 10%

Inpatient deaths

Average MSH score
3
Our target
0

Unplanned readmit depression

Average MSH score
WCL
Since last quarter
No change
Our target
WCL

What we measure

We measure the number of mental health patients who are re-admitted unnecessarily.

Unplanned readmit schizophrenia

Average MSH score
WCL
Since last quarter
No change
Our target
WCL

What we measure

We measure the number of schizophrenia patients who are re-admitted unnecessarily.

Last updated 19 May 2017