Quality, Safety and Performance

Northern Beaches Hospital is committed to continuous improvement of the care and service that we deliver. We evaluate our performance through a robust quality and safety program, key elements include:

  • Strong internal governance and leadership
  • Accreditation by independent, external organisations
  • Ensuring clinical quality and safety is the focus of all hospital activities
  • Sharing the responsibility for clinical excellence between the Executive, all clinical (including doctors) and non-clinical staff
  • Engaging consumers in the design, delivery and evaluation of our services
  • Continuous monitoring, review and improvement of measured outcomes
  • Extensive benchmarking of performance measures with other hospitals
  • Listening and responding to feedback from patients, doctors and staff
  • Publically reporting important quality data.

Working in partnership with our patients is fundamental to our model of care, which is why it's important to us that patients have an understanding of the National Safety and Quality Healthcare Service Standards. The National Standards provide a framework for delivery of the best possible evidence based care. The following information is an overview of each standard, what you can expect from us, and how you can play a part in improving your health outcomes.

Reporting on our Quality and Safety Systems

Measuring healthcare outcomes is an important part of analysing, benchmarking (comparing ourselves to other hospitals) and improving our care and service. We report performance indicators extensively within Healthscope, to NSW Health, and to the Australian Council on Healthcare Standards (ACHS).

You can view our outcomes on the Australian Government website, and on the MyHealthscope website.

Learning from our mistakes

We record and investigate any instances that either result in patient harm, or have the potential to do so. Whilst we take care to maintain staff and patient confidentiality by removing identifying details, reports of any unplanned adverse event are widely shared within Healthscope. We ensure that the staff involved, managers, senior doctors and the hospital Executive are all involved in the review process. This enables us to learn vital lessons, implement changes and reduce or prevent recurrence. If you suffer an unexpected outcome or harm whilst in hospital, our staff are trained to tell you about this in a way that is consistent with the Australian Open Disclosure Framework.

Listening to feedback

We actively seek your comments, concerns and compliments and we invite you to discuss any questions or concerns with our staff at any time.

If you're not sure who to speak with or you need to speak with someone more senior, please ask to speak with the Nurse Unit Manager who will be able to assist you.

Our preference is to manage issues you have during your stay, so that we can improve your experience. However, you can also provide a written comment about your stay by using the feedback forms available in each ward.

All feedback is taken seriously, and if you have a complaint it will be fully investigated and you will receive a formal response. After discharge, a sample of patients will receive an electronic survey about our care and service delivery. Whilst survey completion is voluntary, we value all feedback and use the information to help drive improvement.

Emergency Feedback

Northern Beaches Hospital has comprehensive and fully tested procedures for all potential emergency scenarios.

Each staff member is trained for their respective roles in responding to emergencies.

In the unlikely event of an emergency, please remain in your bed or room, and follow directions from staff.

The hospital regularly conducts fire drills and tests of the alarm system, which is a necessary part of our safety program.

You will hear an overhead message prior to a drill or alarm testing.

We apologise in advance for any disruption caused.

Patient Centred Care

A core part of our philosophy is to provide care that is Patient Centred, which means driven by and focused on individual patient needs. Our model of patient centred care includes:

  • continuity of care and smooth transitions through the healthcare system
  • individualised care planning
  • patient education and support for self-care
  • patient involvement in decision making
  • emotional support, empathy and respect
  • involvement of, and support for, family and carers
  • attention to physical and environmental needs.

Partners in decision making

As a patient you play an essential role in the healthcare team; being actively involved in decision making improves the quality of your healthcare outcomes. In order to make informed decisions, you need to have a good understanding of your condition and treatment options. We have many different education resources available to meet individual circumstances. One of the most important ways we can support your understanding is by ensuring our staff are always open to answering your questions. We recommend that you write down your questions, or you may ask staff to make reminder notes on the patient information board in your room. As a guide, the following questions may help you to best understand your care:

  • What are my options?
  • What are the benefits and harms?
  • How likely are these?

Consumer Consultants

We have a number of Consumer Consultants, some of whom have advised and assisted us throughout the hospital planning process and who continue to provide input into service delivery. Consumer Consultants are vital and provide us with relevant consumer focused feedback and suggestions. Any information developed for patients is first reviewed and edited by our Consumer Consultants. They are invited to review our programs and outcomes, attend patient focus groups and collect patient feedback. Should you wish to learn more about this program please ask to speak to the hospital Quality Manager.

Advanced Care Planning

Advanced Care Planning is a process of thinking about what is important to you about your quality of life, and what matters most at the end of life, and developing a verbal and written record of this. You may develop either an Advanced Care Plan or an Advanced Care Directive. Talking to family and loved ones, whilst not always easy, is an important part of this process. You may also seek advice from your doctor, spiritual advisor and/or legal representative.

If you are admitted in an emergency and unable to communicate, it's often difficult for loved ones to make crucial treatment decisions without guidance of what you would have wanted. Having an Advanced Care Directive offers a way to be involved in decisions about your health, even if you're not in a position to communicate. We recognise the importance of advance care planning, and if you do not have the capacity to decide for yourself or communicate your wishes, your doctor will follow your valid Advanced Care Directive.

An Advanced Care Directive is valid and legally binding if:

  • the person had decision-making capacity when they made it
  • the person was not influenced or pressured by anyone else to make it
  • it has clear and specific details about treatment that they would accept or refuse
  • the person has not revoked it
  • it extends to the situation at hand.

If you have an Advance Care Directive or Advance Care Plan, please let us know as soon as possible after admission.

If you would like to think about the process of advanced care planning for the future, you can access further information via the NSW Health website.

If you are incapable of making or communicating your decisions and there is no clear and valid Advanced Care Directive, your doctor will seek consent for treatment decisions from your 'Person Responsible.'

In NSW, legislation contained in the NSW Guardianship Act determines who can legally consent or decline treatment being offered to you, if you are unable to speak for yourself. This is the Person Responsible.

The treating doctor will identify the Person Responsible according to a hierarchy, as follows:

  • An Enduring Guardian (a person legally appointed by you) or a guardian appointed by the NSW Guardianship Tribunal
  • Your spouse, de facto or same sex partner with whom you have a close ongoing relationship
  • Your carer - a person who provides ongoing, regular care (not a care worker or volunteer)
  • A close friend or relative with whom you have an ongoing relationship
  • If you have any doubts, you should legally appoint your preferred person/s as your Enduring Guardian.

We take every step possible to minimise the risk of hospital acquired infection. Our infection control program is based on a broad range of strategies that include building design and maintenance, environmental cleaning, robust sterilisation processes, safe disposal of clinical waste, effective use of antibiotics, staff education according to best practice principles, and an active surveillance program. However, the single most important measure in reducing hospital acquired infection is hand hygiene.

Hand hygiene is a general term that covers both hand washing with soap and water, and the use of alcohol based hand rub. Our staff are trained to perform hand hygiene in accordance with World Health Organisation guidelines, and patients will be aware of hand gel at each bedside area. Please do not hesitate to remind or check with staff about performing hand hygiene.

Members of the public are asked to perform hand hygiene as you enter and leave our hospital, after going to the toilet, after blowing your nose, before, during and after preparing food, and before and after offering assistance to a patient.

Choose to use alcohol hand rubs when hands are visibly clean, using the following technique:

  • Remove excess jewellery
  • Squirt enough hand rub product to cover both of your hands
  • Roll to distribute over palms, back of hands and between fingers
  • Rub hands together until dry.

Choose to use soap and water when hands are visibly dirty, using the following technique:

  • Remove excess jewellery
  • Wet hands with water
  • Apply soap
  • Rub all over
  • Rinse off with water
  • Pat hands dry with paper towel
  • Dispose of paper towel in bin.

Aseptic Technique

This describes measures we take to protect you from contamination during clinical procedures such as surgery, insertion of medical devices (such as an intravenous cannula), performing a wound dressing, and during the administration of intravenous medications.

Our staff undergo training and assessments to ensure their aseptic technique is of a very high standard.

Invasive Devices

Most patients will need an invasive device at some point during their hospital admission. An invasive device is a general term for a medical device such as intravenous cannula, wound drain, nasogastric tube, urinary catheter, epidural catheter and others. As with any intervention, patients should receive education specific to the care of each device. In general, you can assist us to prevent infection by letting staff know if the dressing is loose or soiled, that the insertion site is painful or changes in any way, and ensuring that anyone handling the device performs hand hygiene before and after doing so.

Transmission Based Precautions

Staff routinely use standard precautions to control the spread of infections, and will do so with all patients. Standard precautions include hand hygiene and protective equipment such as gloves, eyewear and gowns for certain procedures. If a patient is suspected or confirmed as having an infection with the potential to spread to others, additional precautions may be implemented. These additional precautions are based on the mode of transmission the potential infection and may include isolation and additional protective equipment. In this instance, we will offer information and education based on individual circumstances. It is essential that patients and visitors comply with staff instructions and any signage regarding transmission based precautions.

It is important that our staff are aware of all medications that you normally take, including herbal and naturopathic medicines. You must provide us with a complete and accurate list of your current medications on admission to hospital or as soon as possible following your admission.

We will document all existing medications in your medication history and reconcile this with your medication plan whilst in hospital, and your discharge medications once you are transferred to another healthcare provider or to home. We also need you to tell us about any known allergies or sensitivities to medications. This will be documented on your medication chart and in a section of your electronic medical record known as 'Alerts'. If you experience an adverse reaction to medication whilst in hospital, we will investigate and include the information in your discharge summary so it is communicated to other healthcare providers.

Your medications may change whilst you are in hospital and you may be prescribed discharge medications for continued use at home. If your medication requirements change significantly whilst you're with us, if you are on a complicated regime, or if you are prescribed certain medications, a clinical pharmacist will visit you and explain your new medications. If you are at all unclear or would like further clarification of your medications, please speak to your nurse or doctor. You can also ask the Nurse Unit Manager to arrange a clinical pharmacist to visit if you are still concerned. All patients will receive a printed discharge summary that includes a medication record and instructions.

We have strict guidelines for the prescription and administration of medications that aim to minimise the risk of medication error. For example, our nursing staff will ask for your name, date of birth and allergies each time they administer a medication to you. They will confirm your identity against your medication chart and your hospital identification band. Medication administration requires concentration from the nursing staff and interruptions have been shown to increase the risk of error.

You and your Healthcare team are partners in reducing the risks associated with needing an admission to hospital. Throughout your admission, nurses will assess your clinical status and risk of developing known complications. If you are at risk of developing a complication, this will be discussed with you and a treatment plan developed to minimise your risks.

Reducing the Risk of Blood Clots

If you are unwell and in hospital, you are at a much higher than normal risk of developing a blood clot in your leg or lung.

One reason for your risk increasing whilst in hospital is that you are not moving around as much as you normally would.

Because you have had surgery or are unwell, blood flow through the veins can become sluggish and allow a clot to form in your leg. This is called a deep vein thrombosis (DVT). This clot can break apart and some could travel to the lungs, which is called a pulmonary embolism. Both of these can be very serious, which is why we do everything we can to avoid this happening.

Another reason is the body's own protective mechanisms. When you undergo surgery or suffer an injury, the body's natural reaction to stop you from losing too much blood is to make the blood clot easier. Once the initial risk of bleeding has passed or is reduced, unfortunately the tendency to clot can remain, leaving you more likely to develop blood clots in the legs or lungs.

Your doctors and nurses will usually use one or two methods for reducing the risk of forming blood clots: medication or mechanical prevention.

Medication to Prevent Blood Clots

Medications that interfere with the natural clotting process are often known as anticoagulants or 'blood thinners'. These may be administered as a tablet, injected under the skin usually in the stomach, or via an intravenous infusion. Your doctor will decide which is the most appropriate for you - not all patients will require medication.

Mechanical Prevention

Forms of mechanical prevention include graduated compression stockings (sometimes called TEDs), and intermittent compression devices (sometimes called calf compressors). Compression stockings are elasticated stockings that should be properly fitted on admission by your nurse. If they feel uncomfortable or too tight around your leg or toes, or are rolling down or becoming wrinkled, please tell your nurse straight away. The stockings must be worn until you are advised to remove them by your doctor or nurse.

Intermittent Compression Devices are a disposable cuff wrapped around the whole circumference of leg. They automatically inflate and deflate at regular intervals. These are usually removed when you become mobile.

Regardless of the method of prevention prescribed for you, it's important to stay as mobile and active as possible. Movement of the legs stimulates blood flow, so you should try to start moving as soon as possible (even if you are bed bound). Nursing or physiotherapy staff may give you exercises for your legs and feet whilst you are unable to walk, or lying on the bed between walks. The team will assist and encourage you to get up and walk as soon as you are able to do so.

Preventing and Managing Pressure Injuries

A pressure injury (also known as pressure sore, pressure ulcer, or bed sore) is an area of skin that has been damaged due to unrelieved and prolonged pressure. Pressure ulcers may look minor, such as redness on the skin, but they can hide more damage under the skin surface.

Pressure ulcers are usually found on bony parts of the body, but can occur almost anywhere that pressure has been applied for a period of time. Common sites include the buttocks, tail bone, heels, elbows, hips, shoulder blades and back of head.

Almost anyone can develop a pressure injury, but we know that people most at risk include:

  • those confined to a bed or chair and unable to move independently
  • those with loss of sensation or poor circulation
  • those with skin that is frequently moist
  • those with either high or low Body Mass Index, and those with poor nutrition following prolonged surgery.

What can we do to Prevent Pressure Injuries?

Relieve the Pressure

Keeping active and changing position (even slightly) on a regular basis is extremely important. For patients unable to move independently, the nursing staff help you to change position at regular intervals. You may also be provided with special equipment such as air mattresses that will assist to relieve pressure.

Look After your Skin

It is important to keep your skin clean and dry using a mild soap and moisturiser if needed. Please do not hesitate to tell staff if your skin or bedding is damp. Tell staff if you have any pain or discomfort in a particular spot, or if you notice reddened or broken skin. Avoid massaging skin over bony prominences.

Eat as Well as Possible

Good nutrition is an important part of good health generally and preventing or healing pressure injuries specifically. Recognising that this is often a challenging aspect of hospital admission for many reasons, we have a dietetics and catering service designed to offer the best possible nutrition whatever your circumstances. If you have questions about the catering service or would like to speak to a dietician, please speak with your nurse.

Preventing Falls and Harm from Falls

In hospital, your risk of falling, tripping or slipping is increased and you will be surprised at how easy it can be. In addition to the risk of injury, falling over can affect confidence and increase the fear of further falls, making it harder to stay independent.

There are a number of reasons why someone might fall. These include:

  • poor mobility and balance
  • being in an unfamiliar environment
  • badly fitting footwear and clothing
  • urgent need to go to the toilet or incontinence
  • poor eyesight
  • medications that can cause drowsiness or dizziness.

Preventing Falls

  • CALL DON'T FALL - Use your call bell. You may need to use the toilet unexpectedly or more frequently while in hospital. If you need help, or think you need to visit the toilet more often, please ask for assistance. The nurses are here to help you feel as comfortable as possible.
  • Tiled floors, vinyl and other hard surfaces can be slippery, especially if wet or wearing certain types of footwear. Sit down to shower and use the rails for support while standing in the shower. If you feel unsafe, remain seated and ask for assistance.
  • Familiarise yourself with your room and bathroom. Make sure you know the layout of your room and know where everything is.
  • Wear comfortable clothing that is not too long. Loose or full length clothing like pants, pyjamas or dressing gowns can cause you to trip and fall. Make sure these are the right length for you.
  • We strongly recommend that, if possible, patients should bring supportive well-fitting shoes and wear them whenever walking. If this isn't possible, you may be provided with grip socks during your stay.
  • Only wear your distance glasses for walking. Keep them clean and within reach. Be careful when wearing bifocal or multifocal glasses as these can affect your ability to judge depth and distance.
  • At night, use your light button on your call bell to turn on the light before getting out of bed. Turn the light on in the bathroom.

Our Strategies to Prevent Falls

The nurse admitting you will orientate you to your room and the call bell system. The nursing staff will assess your risk of falling on admission and daily thereafter, or if your condition changes. We will implement different prevention strategies depending on your risk. This may range from providing you with grip socks, advising you to wait for supervision or assistance before walking, providing increased nursing supervision, or allied health referrals.

If required, a physiotherapist will assess your mobility and provide you with an appropriate walking aid. They will discuss the outcome of this assessment with you and your family and provide you with education and advice, and an individualised care plan to improve mobility.

We have a system of patient rounding whereby the nurses will proactively visit and, amongst other things, ensure you have your possessions and call bell to hand.

We have further falls prevention information available should you require it - please do not hesitate to ask.

If you do fall, do not try to get up alone. Wait for help to ensure you get back onto your feet safely.


Providing the best possible nutrition is an essential part of helping you recover. All patients are assessed and referred to a dietician for individual care if required. Our dietitians also work with our catering service to ensure we meet the highest possible standards and needs of our patients. We are able to provide menus to meet all dietary requirements, and our menu ordering system links with the medical record so that you are only able to order food that is safe and appropriate for you.

All inpatients are required to wear two identification bands, which will be either red or white. A red band will inform staff that you have an 'Alert' such as a medication allergy or, for example, a history of difficulty with anaesthetics. Please leave your identification band intact until formally discharged from hospital. We are required to check your identity not only for medication administration but prior to performing procedures. Sometimes patients find this repetitive, but it is an important part of our systems for keeping you safe and making sure we are providing the correct treatment to the correct patient.

Effective communication between clinical staff is essential for providing you with coordinated and high quality care. Clinical handover is the transfer of information and responsibility for your care between one person or team to another. Our nursing handovers occur at the bedside and, unless you request otherwise, with your involvement. You are invited to participate by clarifying the information passed on, asking questions if needed, and making requests that address your particular needs. As clinical handover involves discussion of confidential information and a physical assessment, the staff may ask your visitors to leave the room whilst handover takes place. If you would prefer that a family member is present and involved in the process, please let the nursing staff know.

In each room is a patient information board (white or glass board) which contains essential information about your treating team/s and care plans. It is a good communication tool between you and the clinical staff. The staff will update the board at each clinical handover with information such as the nurse looking after you for the oncoming shift, any medical instructions such as dietary regime, and the times of any booked investigations or tests. You should be comfortable with and understand the information displayed.

A transfusion of blood or blood products, when required, can be an essential element of your treatment and recovery. We adhere to national prescribing guidelines and ensure you will not be advised to have a blood transfusion unless necessary. We have extremely strict controls over our transfusion processes and practices to ensure blood transfusion is as safe as possible. If you do require a blood transfusion, unless it is a life threatening emergency, you will be asked by your doctor to provide written consent. You will be supplied with verbal and written information regarding the risks and benefits, and we strongly advise you to discuss with your team if you have any questions around this.

Our staff are trained to recognise and respond to any change in your condition. If you should suddenly deteriorate, we have systems in place to ensure you receive immediate attention from the most appropriate medical and nursing staff. Our emergency response teams will depend on your location and condition, but may include intensive care, anaesthetic or paediatric specialists. We will ensure all information is conferred to your Specialist.

We also strongly support your role, and that of your family, in escalating concerns. If you or your family/friends are worried about a change in your condition, we encourage you/them to call your nurse. If you remain concerned, please ask to speak with the Nurse Unit Manager or doctor. You will have contact details on your patient information board. We support patient and relative involvement and recognise that you know how you feel, or how your relative usually behaves.

If you or your relative feel acutely unwell and in need of immediate medical attention, you can push the emergency red button and a medical team will arrive within minutes. Please do not hesitate to use the button in a genuine emergency.

Mental Health Standards

Our mental health service complies with the Australian National Standards for Mental Health Services. Many of these the standards align with and can be mapped to the National Standards.

The key principles of the mental health standards are:

  • mental health services should promote an optimal quality of life for people with mental health problems and / or mental illness
  • services are delivered with the aim of facilitating sustained recovery
  • consumers should be involved in all decisions regarding their treatment and care, and as far as possible, the opportunity to choose their treatment and setting
  • consumers have the right to have their nominated carer(s) involved in all aspects of their care
  • the role played by carers, as well as their capacity, needs and requirements as separate from those of consumers is recognised
  • participation by consumers and carers is integral to the development, planning, delivery and evaluation of mental health services
  • mental health treatment, care and support should be tailored to meet the specific needs of the individual consumer
  • mental health treatment and support should impose the least personal restriction on the rights and choices of consumers taking account of their living situation, level of support within the community and the needs of their carer(s).

Our Assistance

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