#

The Memorial Hospital

Measures of Hospital Performance


At The Memorial Hospital, we take quality and safety seriously.

To provide you with information about our performance, The Memorial Hospital publishes data which reflects the quality and safety of our care. This is only one part of our program to continually maintain and improve our high standards.

At The Memorial Hospital, quality is not just one simple measure. It includes many aspects of care and of a patient's experience.

Please click on the menu below to view data for each of the indicators we publish.


AtThe Memorial Hospital, we are committed to providing patients with the bestpossible experience during their hospital stay. Patient experience oftenreflects the personal side of care. To evaluate how well we meet patient needs,we invite our patients to complete a survey after discharge. We have based oursurvey on the new Australian Hospital Patient Experience Question Set (AHPEQS)developed by the Australian Commission on Safety and Quality in Health Care(Commission) for use in both public and private health services.

The Memorial Hospital commenced surveying using this tool assoon as it was made available by the Commission in January 2018. Prior to thiswe used the US-based Hospital Consumer Assessment of Healthcare ProvidersSystem (HCAHPS) survey.

Completionof our survey is voluntary and anonymous. Most patients fill in their surveysonline. We conduct surveys continuously throughout the year, which provides uswith feedback that is more accurate than periodic surveys. Sample size has been building as we focus on electronic rather thanpaper survey formats.

Oursenior hospital staff have access to The Memorial Hospital’ssurvey results via an electronicPatient Experience Portal. This allows them to review feedback immediately andidentify any opportunities for improvement. Maintaining anonymity, bothpositive and negative patient comments are shared with relevant staff. This ispart of our commitment to provide the best possible experience for ourpatients.

The Memorial Hospital’s survey results are also continuouslymonitored by the Quality Department and reports are presented to seniormanagement and the Board.

Oneof our key questions about patient experience is the overall quality oftreatment and care, which can be rated on a scale of 1 to 5, from ‘very good’ to ‘very poor’. The graph below shows the percentage of patients whohave rated the quality of their treatment and care overall as ‘very good’ or ‘good’ (top two boxes) over a period of 12 months.


Thisgraph shows that patients’ rating of treatment and care at The Memorial Hospital has been improving, especially the percentageof ‘very good’ ratings. [Data correctas at 16 July 2018.]


What are we doing to enhance patient experience?

The Memorial Hospital employs a variety of strategies toenhance patient experience. These include:

  • Ongoing staff education andprovision of resources to ensure that care is person-focused and of the higheststandard
  • Hospital management constantlymonitoring the rating of overall treatment and care and taking action toaddress any areas of concern
  • Consulting with theClinical Risk / Quality Manager to assist us in implementing strategies toenhance patient experience
  • Engaging ConsumerConsultants who provide feedback from a patient’s or carer’s perspective
  • Involving patients in theircare, for example by shift handover occurring at the bedside
  • Follow-up phone calls topatients after discharge from hospital to ensure they are recovering well
  • Keeping relatives informedof the current location of their loved one in hospital via the ‘Patient Finder’app
  • ‘Patient Journeys’ – volunteerpatients diarising detailed feedback on every part of their hospital experiencefrom pre-admission to post-discharge follow-up
  • Focused initiatives toaddress areas of concern, such as keeping our menu contemporary to suit patientneeds, or measuring of noise levels within different hospital areas

The Memorial Hospital is fully accredited against The National Safety and Quality Health Service Standards, a mandatory set of standards established by the Australian Government for all public and private hospitals.

Accreditation involves a visit to the hospital from an independent team of expert health professionals who review the safety and quality of services provided. Our achievements are measured against industry standards by this review team. Hospitals are measured against ten overarching standards and many different criteria including patient care, medication management, clinical handover, infection control, complaints management and preventing falls.

Hospitals receive a rating for each one of these criteria – either satisfactorily met or not met. If a criterion is not met, the hospital is given an action that it must follow up within three months to ensure the criterion is satisfactorily met.

The Memorial Hospital received a full three year accreditation following organisation wide survey against the National Safety and Quality Health Service Standards in September 2016, gaining satisfactorily met ratings in all the Standard’s Actions, including those that are still in the developmental stage.

The accreditation survey was carried out by the Australian Council on Healthcare Standards (ACHS). The surveyors were impressed with The Memorial Hospital’s staff focus on patients, clients and carers. Staff demonstrated their commitment to the provision of quality care and cohesive teamwork in all aspects of clinical care reviewed. The hospital is well maintained and welcoming for patients and visitors.

The Memorial Hospital’s commitment to quality improvement is ongoing, and current projects include:

  • Implementation of a consumer engagement and participation framework
  • Continued focus on consolidating strategies for Patient Centred Care
  • Focus on improving discharge planning processes
  • Improvement to medication safety practices
  • Improving systems to assess, manage and care for patients with cognitive impairment, delirium or dementia

At The Memorial Hospital we measure the ability, mobility and independence of patients on admission and again on discharge to see how they are improving. We use the internationally recognised FIM™ (Functional Independence Measure), a scale which measures the success of rehabilitation.

It is important to note that rehabilitation outcomes are not solely dependent on the quality of care provided. Patient-specific factors such as age, severity of condition and presence of other health issues can influence how much improvement is achieved.


This chart shows patients with orthopaedic fractures and neurological conditions at The Memorial Hospital are on average older than patients in other Australian hospitals, while patients with joint replacements are of a similar age.


The graph below shows the percentage of patients with a severe impairment on admission. The coloured bar represents The Memorial Hospital's rate. This is compared to the rate in other Australian hospitals, shown in the grey bar.



This chart shows that patients with orthopaedic fractures and neurological conditions at The Memorial Hospital have lower levels of impairment than patients in other Australian hospitals, while patients with joint replacements have similar levels of impairment.


Orthopaedic Fracture Rehabilitation

The graph below shows the improvement in patients after rehabilitation for a fractured bone. The dark coloured bars represent patients' abilities on admission to The Memorial Hospital. The pale coloured bars represent patients' abilities on discharge. This is compared to the outcomes at other Australian hospitals, shown in the grey bars.



This graph shows that rehabilitation patients at The Memorial Hospital have higher scores on both admission and discharge than patients in other Australian hospitals.


Rehabilitation for Hip, Knee or Shoulder Replacement

The graph below shows the improvement in patients after rehabilitation for a joint replacement. The dark coloured bars represent patients' abilities on admission to The Memorial Hospital. The pale coloured bars represent patients' abilities on discharge. This is compared to the outcomes at other Australian hospitals, shown in the grey bars.



This graph shows that rehabilitation patients at The Memorial Hospital achieve outcomes similar to those of patients in other Australian hospitals.



Rehabilitation for Other Neurological Conditions

The graph below shows the improvement in patients after rehabilitation for a neurological condition such as Parkinson's Disease or Multiple Sclerosis. The dark coloured bars represent patients' abilities on admission to The Memorial Hospital. The pale coloured bars represent patients' abilities on discharge. This is compared to the outcomes at other Australian hospitals, shown in the grey bars.




This graph shows that rehabilitation patients with neurological conditions at The Memorial Hospital have higher scores on both admission and discharge than patients in other Australian hospitals.



What are we doing to improve our patients’ outcomes?

The Memorial Hospital employs a variety of strategies to improve our patients' rehabilitation outcomes. These include:

  • A multi-disciplinary team approach, including expert nursing and allied health professionals
  • Individual and group therapy, often including practice of tasks of daily living
  • Depression screening for all stroke patients to support full participation in rehabilitation
  • Swallowing and / or speech / language therapy with a Speech Pathologist


The Memorial Hospital follows strict infection control procedures, and staff take every precaution to prevent infections. Specialised infection control staff collect and analyse data on infections in order to identify and implement best practices to reduce infection rates.

Patients with weakened immune systems, with wounds and with invasive devices such as drips are at greater risk of infection than the general public.

There are several types of infections that we closely monitor at The Memorial Hospital. Two of the most important are:

  • Staphylococcus aureus Bacteraemia – also known as SAB. This is a serious infection caused by bacteria entering the blood stream
  • Clostridium difficile - also known as C Diff. This is an infection of the bowel that causes diarrhoea

The graph below shows the number of Staphylococcus aureus infections at The Memorial Hospital. The coloured bars represent The Memorial Hospital's rate. This is compared to the Australian Government target, shown in the grey bar. The national benchmark for SAB is no more than 2 cases per 10,000 days of patient care.



This graph shows that the rate of SAB infections at The Memorial Hospital is very low and lies well below the Australian government target.


The graph below shows the number of Clostridium difficile infections. The coloured bars represent The Memorial Hospital's rate. This is compared to the rate in other Australian hospitals, shown in the grey bars. The industry rate varies from 2 to 3 cases per 10,000 days of patient care.




This graph shows that the number of ClostridiumDifficile infections at The Memorial Hospital is very low and lies well belowthe industry rate.

What are we doing to prevent infections?

The Memorial Hospital employs a variety ofstrategies to prevent infections. These include:

  • Auditing howoften staff wash their hands using soap and water or hand sanitiser
  • Using gloves andspecialised sterile equipment
  • Assigning adedicated Infection Control Nurse responsible for educating staff andimplementing infection control strategies
  • Usingspecialised disinfectants when cleaning facilities
  • Followingnational guidelines for high level disinfection and sterilisation processes
  • Placing handsanitiser dispensers in public areas throughout the hospital so that they arereadily accessible to staff, patients and visitors


What can you do to help?

At The Memorial Hospital, patients and visitors arepart of the healthcare team. There are a number of things you can do to reducethe risk of infection for yourself and others:

  • Wash your handscarefully with soap and water or use hand sanitiser upon entering the hospital
  • Cover your mouthand nose with a tissue when you cough or sneeze. Clean your hands afterwards –every time!
  • If you don'thave a tissue available, cough or sneeze into your elbow, not your hand
  • As a patient,report any infection you have had, especially if you are still on antibiotics
  • Make sure youtake the full course of antibiotics you have been given, even if you arefeeling better
  • If you have adressing for a wound, keep the skin around the dressing clean and dry. Let thehealthcare worker looking after you know promptly if it becomes loose or wet
  • Tell yourhealthcare worker if the area around any drips, tubes or drains inserted intoyour body becomes red, swollen or painful
  • Let thehealthcare worker looking after you know if your room or equipment hasn't beencleaned properly
  • Stop smokingbefore any surgery, as smoking increases the risk of infection


Visitors

  • Don't visit ifyou have an illness such as a cough, cold or gastroenteritis ('gastro')
  • Wash your handscarefully with soap and water or use hand sanitiser when entering and leaving apatient’s room

Hand Hygiene is another name for hand washing or cleaning. Good hand hygiene is an important part of infection control. Germs can survive on unwashed hands for over an hour, and we can unknowingly transmit bacteria and viruses to others.


All The Memorial Hospital staff are required to wash their hands with soap and water or with waterless hand sanitiser. Both are equally effective. We follow the World Health Organisation's guidelines for hand hygiene, which specify the following times when healthcare staff must wash their hands:

  • Before touching a patient
  • After touching a patient
  • Before a procedure
  • After a procedure
  • After touching a patient’s belongings or surroundings

At The Memorial Hospital, we use auditors who are accredited by Hand Hygiene Australia to record whether or not hand hygiene has been performed correctly. The graph below shows the levels of hand hygiene compliance. The coloured bars represent The Memorial Hospital's rate. This is compared to the Australian national benchmark of 80%, shown in the grey bar.




This graph shows that hand hygiene compliance at The Memorial Hospital is above the national benchmark.

When audits are performed, each professional group is checked – including doctors, nurses, cleaners and other hospital staff.

The first graph below on the left shows which groups were audited. The graph on the right shows the hand hygiene compliance rate for different staff within the hospital. It shows that the compliance rate for all staff groups is very high.




What are we doing to improve hand hygiene?

The Memorial Hospital employs a variety of strategies to improve hand hygiene compliance. These include:

  • Ongoing education programs for staff about infections and hand hygiene
  • A designated Infection Control Nurse responsible for educating staff and implementing infection control strategies
  • Placement of hand sanitiser dispensers in convenient areas throughout the hospital, including hallways and patient rooms
  • Use of specially designed washbasins where water can be turned on and off without touching the tap



What can you do to help?

At The Memorial Hospital, patients and visitors are part of the healthcare team. Good hand hygiene is the most important way in which patients and visitors can prevent the spread of infection in hospital.

There are a number of things you can do:

  • Wash your hands carefully with soap and water or use hand sanitiser upon entering and leaving the hospital
  • Wash your hands carefully with soap and water or use hand sanitiser when entering and leaving a patient’s room
  • Observe hospital signage about hand hygiene
  • If you are unable to find a hand sanitiser station, please ask staff for assistance


Falls are a leading cause of hospital-acquiredinjury and frequently prolong or complicate hospital stays. Patients mayexperience a fall because theyare weakened by a medical condition or after an accident or injury.

The graph below shows the percentage of patientswho have had a fall. The coloured bars represent The Memorial Hospital's rate.This is compared to the rate of falls at otherAustralian hospitals, shown in thegrey bar.




This graph shows that patients at The MemorialHospital have a similar rate of falls to patients in other Australianhospitals. The rate of falls shown for 2017 includes falls that occurred on ourrehabilitation ward/s. Patients undergoing rehabilitation are encouraged to beup on their feet as part of their therapy. For this reason, they may be morelikely to have falls than patients on acute medical / surgical wards, whichexplains the slightly increased rate compared to previous years.

What are we doing to reduce the risk of patientfalls?

The Memorial Hospital employs a variety ofstrategies to reduce the risk of patient falls. These include:

  • Risk assessmentsto identify patients at risk of falling
  • Ongoing staffeducation on falls prevention
  • Patienteducation on prevention of falls in hospital and at home
  • Use of safetyequipment such as lifting hoists, walking aids and chair or bed sensors thatalert staff when a patient at risk of falling gets up unassisted
  • Review of eachfall to assess if there were any preventable factors



Pressure injuries - commonly known as bed sores - are areas of skin damage caused by prolonged pressure. They can range in severity from an area of reddened skin to ulcers with underlying tissue damage.

Pressure injuries can sometimes occur when a patient remains in one position for a long period. Certain people are at increased risk of developing pressure injuries, such as the elderly, people who are bedbound or have poor mobility and people with chronic conditions like diabetes.

This graph below shows the number of patients who have developed a pressure injury during their admission to hospital. The coloured bars represent The Memorial Hospital's rate. This is compared to the rate of pressure injuries in other Australian hospitals, shown in the grey bar.



This graph shows that patients at The Memorial Hospital are less likely to develop a pressure injury than patients in other Australian hospitals.


What are we doing to minimise the risk of pressure injuries?

The Memorial Hospital employs a variety of strategies to minimise the risk of patients developing pressure injuries. These include:

  • Risk assessments to identify patients who are susceptible to pressure injuries
  • Ongoing education for nursing staff in pressure injury identification, prevention and management
  • Patient education on prevention of pressure injuries in hospital and at home
  • Use of pressure-relieving devices such as special mattresses, cushions, wedges, sheepskins, water-filled supports, contoured or textured foam supports, heel elevators and supports filled with gel or beads
  • Regularly changing patients' position and encouraging walking or movement if possible
  • Referral to a wound management consultant if a pressure injury is identified
  • Review of each pressure injury acquired in hospital to assess if there were any preventable factors




A blood transfusion is the transfer of blood orblood products such as platelets or plasma into a patient's vein, usually viaan intravenous (IV) cannula. Transfusions may be necessary when a patient:

  • Has lost a largeamount of blood
  • Is unable toproduce parts of their own blood
  • Has blood cellsthat are not functioning properly

Transfusions are carried out on doctor's orders bytrained professional staff, in accordance with the NationalSafety and Quality Health Service Standards andwith the patient's consent. The Memorial Hospital audits this on a regularbasis.

A blood transfusion can be lifesaving orsignificantly improve quality of life. Australia has one of the safest bloodsupplies in the world, but no blood transfusion is completely without risk.While adverse events are rare, they may include:

  • Transfusion ofincorrect blood / blood component
  • Transmission ofinfection, for example bacteria or viruses
  • Transfusion-relatedimmune reaction
  • Transfusion-relatedacute lung injury

The graph below shows the number of patients at TheMemorial Hospital who had a transfusion with no significant adverse event. Thecoloured bars represent The Memorial Hospital's rate. This is compared to therate of successful transfusion events in other Australian hospitals, shown in the grey bar.




This graph shows that patients at The Memorial Hospitalare less likely to have an adverse transfusion event compared with patients in other Australian hospitals.


What are we doing to reduce the risk of adversetransfusion events?

The Memorial Hospital employs a variety ofstrategies to reduce the risk of adverse transfusion events. These include:

  • Avoidingunnecessary blood transfusions by use of medications and non-blood treatments
  • Identifying anyrisk factors for adverse reactions before the transfusion commences
  • Carefulcross-matching of blood groups to make sure no errors occur
  • Ongoing trainingfor nursing staff involved in blood transfusion administration
  • Patienteducation and provision of written materials explaining blood transfusions
  • Careful monitoringof patients during administration of a blood transfusion
  • Working closelywith the pathology laboratory that provides the blood
  • Review of eachadverse transfusion event to assess if there were any preventable factors

TheMemorial Hospital has a National Transfusion Governance Committee that overseesbest practice standards for transfusion management in our hospitals and reviewsadverse events nationally, so that all hospitals can learn from them.

Following discharge from hospital, patients may sometimes require an unplanned readmission. There are many reasons why a patient may need to return to hospital, such as a surgical wound infection that occurred after the initial hospital stay.

Good discharge planning can help reduce the rate of unplanned readmissions. This includes making follow-up arrangements, providing patients with clear care instructions and helping them recognise symptoms that require immediate medical attention.

The graph below shows the percentage of patients who have required an unplanned readmission to hospital within 28 days of their first admission. The coloured bars represent The Memorial Hospital's rate bars. This is compared to the rate of unplanned readmissions in other Australian hospitals, shown in the grey bar.



This graph shows that patients admitted to The Memorial Hospital are less likely to have an unplanned readmission compared with patients in other Australian hospitals.

Please note: The unplanned readmission rates presented in this graph only include patients who have been readmitted to the same hospital. Currently, we have no way of measuring unplanned readmissions to a different hospital.


What are we doing to minimise unplanned re-admissions?

The Memorial Hospital employs a variety of strategies to minimise unplanned readmissions. These include:

  • Discharge processes which ensure that patients understand their medications and any post-operative instructions
  • Arranging appropriate follow-up care and ongoing appointments, eq, with the General Practitioner or Physiotherapist
  • Review of each unplanned readmission to assess if there were any preventable factors

Following a procedure in the operating theatre,patients sometimes need an unplanned second operation. This iscalled 'return to theatre’. There are many reasonswhy a patient may require a further operation, such as complications from thefirst procedure or an unrelated matter.

The graph below shows the percentage of patientswho have required a return to theatre after having an operation at The MemorialHospital. The coloured bars represent The Memorial Hospital's rate. This iscompared to the rate of return to theatre in otherAustralian hospitals, shown in the grey bar.




This graph shows that in 2017, patients undergoingsurgery at The Memorial Hospital were less likely to have an unexpected returnto theatre than patients in other Australian hospitals.


What are we doing to minimise unplanned returns totheatre?

The Memorial Hospital employs a variety ofstrategies to minimise unplanned returns to theatre. These include:

  • Pre-admissionassessment of patients with particular risk factors to ensure that allprecautions are taken
  • Carefulmonitoring of patients in recovery
  • Review of allunplanned returns to theatre to assess if there were any preventable factors

Following surgery, all patients require closemonitoring. This monitoring typically happens in the Recovery Unit. For somemajor operations, such as heart surgery, an admission to the Intensive CareUnit may be planned to allow monitoring with specialised equipment.

Occasionally, a patient may have an unexpectedreaction to the anaesthetic or a complication from surgery and will require anunplanned admission to Intensive Care.

The graph below shows the percentage of patientswho have required an unplanned admission to the Intensive Care Unit within 24hours of their operation. The coloured bars represent The Memorial Hospital'srate. This is compared to the rate of unplanned admission to Intensive Care in other Australian hospitals, shown in thegrey bar.




This graph shows that patients admitted to TheMemorial Hospital are less likely to have an unplanned admission to IntensiveCare compared with patients in other Australian hospitals.


What are we doing to minimise unplanned admissionsto Intensive Care?

Flinders Private Hospital employs a variety ofstrategies to minimise unplanned admissions to Intensive Care. These include:

  • Pre-admissionassessment of patients with particular risk factors to ensure that allprecautions are taken
  • Advance bookingsof Intensive Care beds for patients who have specific risk factors
  • Review of eachunplanned admission to Intensive Care to assess if there were any preventablefactors

Many organisations today are measuring quality in healthcare using varying criteria. Evaluating this information can be difficult and time consuming since not all measures reflect the same information from one report to another. However, it is important for patients to ask questions and look at quality information to ensure they are getting the efficient and effective care they need.

The Memorial Hospital is a member of the Adelaide Community Healthcare Alliance Incorporated (ACHA). ACHA and its contracted manager Healthscope, supports transparent public reporting of healthcare quality data and actively participates in initiatives of the following organisations.

Australian Commission on Safety and Quality in Healthcare (ACSQHC) – The Australian Commission on Safety and Quality in Healthcare (the Commission) was established in 2006 by the Australian, State and Territory Governments to lead and coordinate national improvement in safety and quality. Healthscope (ACHA’s contracted manager) has representation on the Private Hospital Sector Advisory Committee and several key working groups.

Australian Institute of Health and Welfare - The Australian Institute of Health and Welfare (AIHW) is a major national agency set up by the Australian Government under the Australian Institute of Health and Welfare Act to provide reliable, regular and relevant information and statistics on Australia's health and welfare.

MyHospitals Website – This website lists all public and private hospitals in Australia, along with information about waiting times for elective surgery and emergency department access. Healthscope (ACHA’s contracted manager) - has representation on the MyHospitals Development Advisory Committee.

Our Assistance

... ... ... ... ...