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'Clinical governance' is a series of systems designed to reduce harm to patients.
We set standards 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.
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.
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.
We track the death rate of heart attacks for people admitted to our hospitals.
We track the death rate of strokes for people admitted to our hospitals.
We track the death rate of broken hips (NOF - neck of femur) for people admitted to our hospitals.
We track the death rate of pneumonia for people admitted to our hospitals.
We track the number of stroke patients who are cared for in a specialised unit.
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.
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.
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.
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.
We audit the number of senior doctors who have had their medical credentials (qualifications) assessed.
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.
Every two years we check that each of our clinical units is undertaking proper audits and reviews of their care. Audit and review of care helps improve patient care.
We compare ourselves with other hospitals and health services throughout Australia on how patients view their nursing care.
We audit the rates of hand washing by staff. Hand washing has been proven to help prevent the spread of infection.
We check to make sure we give antibiotics as required to help prevent infections in people who have an operation.
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.
We track how quickly we give antibiotics to patients coming to the emergency department who might have sepsis.
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.
This is a system for measuring our medication safety. It asks 240 questions and compares our results with other Australian hospitals and health services.
We track the number of patients whose medications have been checked and recorded by a pharmacist for accuracy and completeness when they leave hospital.
We check to ensure that we properly manage any patients whose warfarin levels are too high. Warfarin is a very useful medication but if the levels are too high it can lead to bleeding.
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.
We track our idenfication rates to make sure we don't get patients mixed up and give the wrong care to the wrong patient.
We track the number of patients who were informed of the risks and benefits of the procedure and subsequently consented to it. This ensures patients are willing to go ahead with a procedure.
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.
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.
We track the number of blood transfusions for patients with haemoglobin (Hb) levels of greater than 100. This helps us reduce unnecessary transfusions.
We track the number of patients who have been informed of the risks and benefits of, and consented to, a transfusion. This ensures that patients are willing to go ahead with a transfusion.
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.
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 12 hours of being admitted to hospital.
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.
We measure the number of patients at risk of malnutrition due to their illness who have had a nutrition care plan completed.
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.
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.
We track the rates of follow-up for mental health patients after they leave hospital. This helps prevent self-harm.
We measure the number of mental health patients who are re-admitted unnecessarily.
We measure the number of schizophrenia patients who are re-admitted unnecessarily.
This experimental measure is assessing if we can reduce the number of times diabetic patients with leg injuries are admitted to hospital.