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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.


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 quality and safety of services provided. This occurs every three years, in accordance with the Australian Commission on Quality and Safety in Health Care. The hospital is measured against eight overarching standards with many different criteria, including patient-centred care, medication management, clinical handover, infection prevention and staff education.

At the most recent survey, Memorial Hospital achieved full accreditation. The hospital's accreditation report can be viewed here.

At The Memorial Hospital, we are committed to providing patients with the best possible experience during their hospital stay. Patient experience often reflects 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 our survey 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 as soon as it was made available by the Commission in January 2018. Prior to this we used the US-based Hospital Consumer Assessment of Healthcare Providers System (HCAHPS) survey.

Completion of our survey is voluntary and anonymous. Most patients fill in their surveys online. We conduct surveys continually throughout the year, which provides us with feedback that is more accurate than periodic surveys. Sample size has been building as we focus on electronic rather than paper survey formats.

Our senior hospital staff have access to The Memorial Hospital’s survey results via an electronic Patient Experience Portal. This allows them to review feedback immediately and identify any opportunities for improvement. Maintaining anonymity, both positive and negative patient comments are shared with relevant staff. This is part of our commitment to provide the best possible experience for our patients.

The Memorial Hospital’s survey results are also continuously monitored by the Quality Department and reports are presented to senior management and the Board.

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


This graph shows that the ratings of overall quality of treatment and care have been improving. Especially the percentage of 'very good' ratings has increased since 2017. Since late 2017, combined 'good' and 'very good' ratings have been consistently above 90%. [Data correct as at January 2019.]


What are we doing to improve patient experience?

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

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

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 FIMâ„¢ (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 rehabilitation 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 Clostridium Difficile infections at The Memorial Hospital is very low and lies well below the industry rate.


What are we doing to prevent infections?

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

  • Auditing how often staff wash their hands using soap and water or hand sanitiser
  • Using gloves and specialised sterile equipment
  • Assigning a dedicated Infection Control Nurse responsible for educating staff and implementing infection control strategies
  • Using specialised disinfectants when cleaning facilities
  • Following national guidelines for high level disinfection and sterilisation processes
  • Placing hand sanitiser dispensers in public areas throughout the hospital so that they are readily accessible to staff, patients and visitors

What can you do to help?

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

  • Wash your hands carefully with soap and water or use hand sanitiser upon entering the hospital
  • Cover your mouth and nose with a tissue when you cough or sneeze. Clean your hands afterwards –every time!
  • If you don't have 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 you take the full course of antibiotics you have been given, even if you are feeling better
  • If you have a dressing for a wound, keep the skin around the dressing clean and dry. Let the healthcare worker looking after you know promptly if it becomes loose or wet
  • Tell your healthcare worker if the area around any drips, tubes or drains inserted into your body becomes red, swollen or painful
  • Let the healthcare worker looking after you know if your room or equipment hasn't been cleaned properly
  • Stop smoking before any surgery, as smoking increases the risk of infection

Visitors

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

For more information about how you can help:

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 nurses is higher than other groups.


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

For more information on how you can help:


Falls are a leading cause of hospital-acquired injury and frequently prolong or complicate hospital stays. Patients may experience a fall because they are weakened by a medical condition or after an accident or injury.

The graph below shows the percentage of patients who have had a fall. The coloured bars represent The Memorial Hospital's rate.This is compared to the rate of falls at other Australian hospitals, shown in the grey bar.




This graph shows that patients at The Memorial Hospital have a similar rate of falls to patients in other Australian hospitals. The rate of falls shown for 2017 includes falls that occurred on our rehabilitation ward/s. Patients undergoing rehabilitation are encouraged to be up on their feet as part of their therapy. For this reason, they may be more likely to have falls than patients on acute medical / surgical wards, which explains the slightly increased rate compared to previous years.


What are we doing to reduce the risk of patient falls?

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

  • Risk assessments to identify patients at risk of falling
  • Ongoing staff education on falls prevention
  • Patient education on prevention of falls in hospital and at home
  • Use of safety equipment such as lifting hoists, walking aids and chair or bed sensors that alert staff when a patient at risk of falling gets up unassisted
  • Review of each fall 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 or blood products such as platelets or plasma into a patient's vein, usually via an intravenous (IV) cannula. Transfusions may be necessary when a patient:

  • Has lost a large amount of blood
  • Is unable to produce parts of their own blood
  • Has blood cells that are not functioning properly

Transfusions are carried out on doctor's orders by trained professional staff, in accordance with the National Safety and Quality Health Service Standards and with the patient's consent. The Memorial Hospital audits this on a regular basis.

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

  • Transfusion of incorrect blood / blood component
  • Transmission of infection, for example bacteria or viruses
  • Transfusion-related immune reaction
  • Transfusion-related acute lung injury

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

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


What are we doing to reduce the risk of adverse transfusion events?

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

  • Avoiding unnecessary blood transfusions by use of medications and non-blood treatments
  • Identifying any risk factors for adverse reactions before the transfusion commences
  • Careful cross-matching of blood groups to make sure no errors occur
  • Ongoing training for nursing staff involved in blood transfusion administration
  • Patient education and provision of written materials explaining blood transfusions
  • Careful monitoring of patients during administration of a blood transfusion
  • Working closely with the pathology laboratory that provides the blood
  • Review of each adverse transfusion event to assess if there were any preventable factors

The Memorial Hospital is a member of Healthscope's National Transfusion Governance Committee that oversees best practice standards for transfusion management in our hospitals and reviews adverse 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 re-admissions to a different hospital.

What are we doing to minimise unplanned re-admissions?

The Memorial Hospital employs a variety of strategies to minimise unplanned re-admissions. 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 is called 'return to theatre’. There are many reasons why a patient may require a further operation, such as complications from the first procedure or an unrelated matter.

The graph below shows the percentage of patients who have required a return to theatre after having an operation at The Memorial Hospital. The coloured bars represent The Memorial Hospital's rate. This is compared to the rate of return to theatre in other Australian hospitals, shown in the grey bar.

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

What are we doing to minimise unplanned returns to theatre?

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

  • Pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
  • Careful monitoring of patients in recovery
  • Review of all unplanned returns to theatre to assess if there were any preventable factors

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

Occasionally, a patient may have an unexpected reaction to the an aesthetic or a complication from surgery and will require an unplanned admission to Intensive Care.

The graph below shows the percentage of patients who have required an unplanned admission to the Intensive Care Unit within 24 hours of their operation. The coloured bars represent The Memorial Hospital's rate. This is compared to the rate of unplanned admission to Intensive Care 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 admission to Intensive Care compared with patients in other Australian hospitals.

What are we doing to minimise unplanned admissions to Intensive Care?

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

  • Pre-admission assessment of patients with particular risk factors to ensure that all precautions are taken
  • Advance bookings of Intensive Care beds for patients who have specific risk factors
  • Review of each unplanned admission to Intensive Care to assess if there were any preventable factors

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.

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