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Clinical Governance scorecard - July-December 2015

Reporting period: 
1 July 2015 to 31 December 2015

'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
0.5
Since last quarter
Declining
Best performing hospital/services
0
Most improved hospital/service
N/A
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
58
Since last quarter
No change
Best performing hospital/services
44
Most improved hospital/service
67
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
No change
Best performing hospital/services
WCL
Most improved hospital/service
LL3
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
No change
Best performing hospital/services
WCL
Most improved hospital/service
LL1
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
LL2
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
No change
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
88%
Since last quarter
Improving
Best performing hospital/services
94%
Most improved hospital/service
74%
Our target
> 75%

What we measure

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

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

Average MSH score
90%
Since last quarter
No change
Best performing hospital/services
93%
Most improved hospital/service
88%
Our target
> 80%

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
83%
Since last quarter
Declining
Best performing hospital/services
90%
Most improved hospital/service
91%
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
95%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
86%
Our target
> 80%

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
96%
Since last quarter
Declining
Best performing hospital/services
100%
Most improved hospital/service
81%
Our target
> 97%

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
100%
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
93%
Since last quarter
No change
Best performing hospital/services
100%
Most improved hospital/service
88%
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.

Clinical audit and review standard compliance

Average MSH score
94%
Since last quarter
Declining
Best performing hospital/services
100%
Most improved hospital/service
80%
Our target
> 80%

What we measure

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.

NSQHS 2: Partnering with Consumers

Patient satisfied with Nurses meeting most important expectations

Average MSH score
95%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
91%
Our target
> 90%

What we measure

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

NSQHS 3: Preventing and Controlling Healthcare Associated Infections

Hand hygiene compliance

Average MSH score
81%
Since last quarter
Declining
Best performing hospital/services
91%
Most improved hospital/service
64%
Our target
> 70%

What we measure

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

Surgical antibiotic prophylaxis

Average MSH score
98%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
93%
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
0.26
Since last quarter
Improving
Best performing hospital/services
0
Most improved hospital/service
1.3
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.

Time to antibiotics in patients with sepsis

Average MSH score
63%
Since last quarter
Declining
Best performing hospital/services
96%
Most improved hospital/service
44%
Our target
> 80%

What we measure

We track how quickly we give antibiotics to patients coming to the emergency department who might have sepsis.

NSQHS 4: Medication Safety

Weekend pharmacist medication reconciliation

Average MSH score
36%
Since last quarter
Declining
Best performing hospital/services
67%
Most improved hospital/service
20%
Our target
> 30%

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.

Medication safety self assessment score

Average MSH score
60%
Since last quarter
Improving
Best performing hospital/services
67%
Most improved hospital/service
55%
Our target
> 60%

What we measure

This is a system for measuring our medication safety. It asks 240 questions and compares our results with other Australian hospitals and health services.

Electronic medication discharge summaries

Average MSH score
92%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
71%
Our target
> 50%

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
72%
Since last quarter
No change
Best performing hospital/services
99%
Most improved hospital/service
23%
Our target
> 85%

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%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
83%
Our target
> 80%

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
97%
Since last quarter
Improving
Best performing hospital/services
100%
Most improved hospital/service
91%
Our target
> 94%

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 7: Blood and Blood Products

Single unit red cell transfusion episodes

Average MSH score
34%
Since last quarter
Improving
Best performing hospital/services
35%
Most improved hospital/service
32%
Our target
> 19%

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.

Transfusions given to patients with haemoglobin >100

Average MSH score
1.3%
Since last quarter
No change
Best performing hospital/services
0.2%
Most improved hospital/service
3.0%
Our target
≤ 0.3%

We track the number of blood transfusions for patients with haemoglobin (Hb) levels of greater than 100. This helps us reduce unnecessary transfusions.

NSQHS 8: Preventing and Managing Pressure Injuries

Hospital acquired pressure ulcer prevalence

Average MSH score
4%
Since last quarter
No change
Best performing hospital/services
0%
Most improved hospital/service
9%
Our target
≤ 11.1%

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.

Compliance with skin inspection within 12 hours of admission

Average MSH score
64%
Since last quarter
Declining
Best performing hospital/services
76%
Most improved hospital/service
39%
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 12 hours of being admitted to hospital.

Patients with weight recorded on admission

Average MSH score
72%
Since last quarter
Declining
Best performing hospital/services
85%
Most improved hospital/service
46%
Our target
≥ 80%

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
85%
Since last quarter
Declining
Best performing hospital/services
100%
Most improved hospital/service
71%
Our target
≥ 80%

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 10: Falls Prevention

Falls risk assessment completed

Average MSH score
75%
Since last quarter
No change
Best performing hospital/services
92%
Most improved hospital/service
36%
Our target
≥ 70%

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
70%
Since last quarter
No change
Best performing hospital/services
85%
Most improved hospital/service
48%
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

Consumer 7-day follow up after discharge

Average MSH score
69%
Since last quarter
Declining
Best performing hospital/services
N/A
Most improved hospital/service
N/A
Our target
> 60%

What we measure

We track the rates of follow-up for mental health patients after they leave hospital. This helps prevent self-harm.

Unplanned readmit depression

Average MSH score
11%
Since last quarter
No change
Best performing hospital/services
N/A
Most improved hospital/service
N/A
Our target
< 12%

What we measure

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

Unplanned readmit schizophrenia

Average MSH score
20%
Since last quarter
No change
Best performing hospital/services
N/A
Most improved hospital/service
N/A
Our target
< 12%

What we measure

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

Experimental Measures

Diabetic lower limb complication admission rate

Average MSH score
14.5%
Since last quarter
Declining
Best performing hospital/services
14.5%
Most improved hospital/service
14.5%
Our target
< 10%

What we measure

This experimental measure is assessing if we can reduce the number of times diabetic patients with leg injuries are admitted to hospital.

Last updated 26 May 2016