2016 Annual Report on Safety and Quality
Mission Statement
Coburg Endoscopy Centre (CEC) is committed to being a leader in patient care by providing an optimal level of clinical service in the fields of Endoscopy.
Our team of experienced specialists and staff are dedicated to the delivery of appropriate medical care with due consideration to our patients' rights to privacy, dignity and informed consent.
CEC acknowledges its duty of care responsibilities in line with the National Safety and Quality Health Service Standards including the Equip National Day procedure standards and other relevant legislative and regulatory requirements. This focus is demonstrated throughout CEC’s
- Governance and quality improvement systems, including infection prevention, control and surveillance, medication safety and clinical handover processes
- Clinical practice
- Performance and skill management
- Patient identification and procedure matching processes
- Pressure injury prevention and management strategies
- Clinical recognition and response systems
- Falls prevention and management strategies
- Service and Care delivery
- Workforce planning and management
- Information management
- Organisational systems
- Systems for safety
Quality Commitment
Coburg Endoscopy is certified with The Australian Council on Healthcare Standards. Our facility services are audited by a certified accreditor on a regular basis.
Our certification ensures ongoing compliance and improvements with the National Safety and Quality in Health Service Standards.
Our facility is licenced and regulated by The Department of Health, Victoria and undergoes compliance audits relating to the Private Hospitals Health Act, 2013.
Safety & Quality Programs
All staff at Coburg Endoscopy are provided with opportunities to engage in improving clinical practice, engaging with our patients, increasing knowledge base for best practice and guidelines, improving work health and safety.
Staff education and competency training includes: Infection Prevention and Control Practices, CPR and Basic Life Support, Patient Centred Care, Open Disclosure, Hand Hygiene, Medication Safety, Fire and Emergency Training, Manual Handling and Occupational Health and Safety training.
Infection Prevention and Control
Coburg Endoscopy has a comprehensive infection prevention and control program in place. Our facility and staff are regularly audited for compliance with national infection prevention and control guidelines, Australian Standards for reprocessing of reusable instruments and the Australian Commission of Safety and Quality in Healthcare (ACSQHC), National Safety and Quality Health Service Standards.
Reporting and Auditing
Coburg Endoscopy Board of Management and staff are committed and engaged in risk and incident reporting. This is pivotal in improving all our safety and quality systems.
All sentinel (serious) events and incidents or risks at Coburg Endoscopy are reported to The Department of Health and the Board of Management including the Medical Advisory Committee as appropriate.
There were no sentinel (serious) reports to the Department of Health for 2016.
Results of auditing and reports for 2016
- Hand hygiene and Infection Prevention and Control audits - consistently above the National benchmark of 85% and at a high level of compliance.
- Post procedure Infections - 0 %
- Patient falls/ pressure injuries/ skin tears - one patient fall, no pressure injuries
- Medication management system and incidents - no incidents of medication errors; consistently high levels of compliance with medication documentation and legislative requirements.
- Clinical processes audited include: Patient identification/procedure matching, clinical handover.
- Clinical Indicators for Day Surgery are collected and submitted to the ACHS Clinical Indicator program and results benchmarked with other facilities.
- Medical record audits - compliant with legislative requirements.
- Patient feedback - Patient satisfaction surveys are comprehensive and show a consistently high level of satisfaction with Coburg Endoscopy services.
- Medical practitioner credentialing - all Endoscopists and Anaesthetists (Visiting Medical Officers) at Coburg Endoscopy are compliant with Department of Health Credentialing and Defining the Scope of Practice and Registration (AHPRA) requirements prior to beginning work and annually thereafter. Our current compliance rate is 100%.
- Staff satisfaction surveys are conducted annually and show a consistent level of support for processes and employment at Coburg Endoscopy.
If you would like a copy of all results to our quality and safety reports, please contact:
Coburg Endoscopy’s Director of Nursing, Charlene Cefai on 9386 4422.
Patient and Consumer Participation in our Safety and Quality
In 2016, Coburg Endoscopy will commence a patient participation program. This will provide a formal process for reviewing and improving our safety and quality initiatives, while providing a forum for consumer and patient feedback.
If you would like to be involved, please contact:
Coburg Endoscopy’s Director of Nursing, Charlene Cefai, on 9386 4422.
In the patient waiting area you will find a suggestion/comments form and a suggestion box.
We encourage ALL patients and carers/relatives to provide productive feedback to our executive and staff.
All visitors to Coburg Endoscopy are encouraged to participate in infection prevention and control by using our hand hygiene products and practising correct cough etiquette. Information on this is provided in our patient information folder.
Carers and relatives are able to assist in patient safety by alerting our staff immediately if their relative (or someone else) becomes unwell or they are worried about them in the patient waiting areas.
Emergency call bells are available to patients in all our patient care areas and amenities, and are available in a variety of languages.