SAFETY & QUALITY
Our Ballarat Surgicentre Quality Objectives for 2019-2020 are:
- To meet all relevant health authority requirements.
- Provide a high level of professional care to patients.
- Provide + support high standards of medical technology for patients, consumers and staff by utilising developments in technology.
- Develop and achieve a high level of staff involvement and ensure a consumer focused team approach to all patient and doctor services.
- Maintain the best clinical standards through strategic staff recruitment, staff training, peer review and update, quality assurance programs and critical evaluation of services.
- To ensure consumers are active participants in governance planning and the design, measurement and evaluation of healthcare.
- To ensure we meet the needs of specific patient groups as and when required. E.g. Aboriginal and Torres Strait Islander people, those with communication issues (cognitive impaired, health literacy, language barriers) and mental health issues.
Risk management underpins the safety and quality program at the Ballarat Surgicentre. We use the principles of risk management in the day to day functions of the facility. The risk management program aims to avoid, reduce occurrence or reduce consequences of the identified risk. To ensure compliance with all standards, regulations and legislation, the Ballarat Surgicentre completes extensive internal and external auditing and surveillance.
All Auditing findings are discussed at regular Board of Management meetings and distributed to staff and consumers throughout the year.
The Board of Management is responsible for the quality and safety of Health services provided at Ballarat Surgicentre.
The Ballarat Surgicentre works closely with Infection Prevention Victoria and has a comprehensive infection prevention and control program in place. Our facility and staff are regularly audited for compliance with:
• AS/NZS 4187:2014 – Reprocessing of Reusable Medical Devices in Health Service Organisations
• 2018 ACORN Standards for Perioperative Nursing
• NHMRC – Australian Guidelines for the Prevention and Control of Infection 2019
• Hand Hygiene
The Ballarat Surgicentre has processes for continually assessing the capacity of its facility to provide a safe, patient centered and appropriate health services to patients. All processes are listed in policies and procedures which are accessible to all staff and consumers by contacting our Director of Nursing, Mrs Kelly Buckland.
Patient Pre-Admission Risk Assessments
Our Clinical team carry out Patient risk-assessments prior to all surgery admissions. If a patient does not meet our admission criteria, then the treating doctor will make alternative suitable arrangements.
The Ballarat Surgicentre has a Credentialing of Medical and Nursing Staff Policy (MSP- 06). This policy is to ensure that all staff are appropriately credentialed and have their scope of practice defined in accordance with their level of skill and experience. Medical Practitioner credentialing is in accordance with Credentialing and Scope of Clinical Practice for Senior Medical Practitioners Policy 2018 and Department of Health Service Regulations.
Open disclosure is the process of open communication with the patient, and or their family/support person, following an adverse or unexpected event that may or may not result in harm to the patient. The Ballarat Surgicentre has an Open Disclosure policy (MSP- 36), which outlines this process.
The Ballarat Surgicentre operates under medical by-laws that support and facilitate a quality health service that delivers safe care. The Medical By-laws:
• Establish the principles applying to the accreditation and defining scope of practice of practitioners
• Govern the relationship of the Ballarat Surgicentre with its accredited practitioners
• Set out the rules for the conduct of accredited practitioners at the Ballarat Surgicentre
• Outline the obligations on accredited practitioners in relation to the safety and quality of care of patients
• Ensure that a clinical governance framework is in place to evaluate, monitor and improve quality and safety of the health service provided
• Set out the scope of practice for services the facility can safely support
To view a full copy of the current Ballarat Surgicentre Medical By-Laws, please click here.
Staff complete a mandatory orientation program and training which is monitored and reviewed annually. (MSP- 08). They also undertake regular Staff performance reviews and appraisals where their developmental progress and goals are reviewed.
Should you like any further information on our Risk Management system, Pre-Admission Risk Assessment process, Credentialing of Staff policy or Open Disclosure policy, please contact our Director of Nursing, Mrs Kelly Buckland on 03 5303 0190.
The Ballarat Surgicentre respects your personal and health care information in accordance with Federal and State Legislative requirements. All information collected is with your consent, protected and disclosed only for the primary purposes of and directly related secondary purposes of your Hospital Admission. Information is stored securely and includes clinical photographs that can be kept on your medical record.
Information is not disclosed to any unauthorised third party without your knowledge or consent. For further information pertaining to our Health Record keeping, Confidentiality and Privacy processes, please contact our Director of Nursing, Mrs Kelly Buckland on (03) 5303 0190.
The Health Legislation Amendment and Repeal Act 2019 introduced a series of new information sharing provisions in the form of a new Part 6B “Information sharing for quality and safety purposes” to be inserted into the Health Services Act 1988. The new provisions will commence on 27th of August 2020.
What is changing?
The new information sharing provisions are intended to enhance the quality and safety of the Victorian health system by expressly authorising the Department of Health and Human Services, quality and safety bodies (i.e. Safer Care Victoria and the Victorian Agency for Health Information), and health service entities to share confidential information about an individual (such as patient or clinician) for quality and safety purposes. The provisions are intended to improve the flow of information to identify deficiencies in care and focus attention on opportunities for improvement.
There is not a requirement for the individual to consent to or be notified about the information being shared. Any sharing would be subject to and comply with existing data security and storage requirements set out in the Health Privacy Principles and Information Privacy Principles. This sharing will be authorised by the Health Services Act (as amended) and is intended to support continuous service improvement.
Ballarat Surgicentre Quality Policy
To provide quality, safe and a caring service in a friendly and professional Day Hospital environment. The Ballarat Surgicentre is committed to improvement and development of its service through the regular monitoring and assessment of current practices and policies.
We strive to be a leading healthcare provider and an employer of choice, supporting the needs of our growing Ballarat community. Our partnerships with consumers, carers and professionals provide a collaborative approach to the planning, design and evaluation of health care delivery. We plan to provide a service and experience that is above and beyond the expectations of our patients.
• Providing the best available care to our patients.
• Providing the best available service to our Medical Practitioners and the external medical community.
• Providing a safe and quality health care service to our community.
• Meet all required standards and legislative requirements.
• Meet the needs of all other relevant interested parties.
• Provide a dynamic, supportive environment that assists all staff to be their best.
The Ballarat Surgicentre has a Management System which is based on AS/NZS ISO 9001: 2016, the International Standard for Quality Management and the National Safety and Quality Health Service Standards (NSQHS second edition).
Ballarat Surgicentre has developed processes for planning to facilitate a transparent management system, which involves all team members. The outcome of our planning process is a set of objectives, which are reviewed and updated on an annual basis.
• Are aware of the requirements of our management systems.
• Identify, report, record all problems, incidents, complaints, or areas of improvements.
• Comply with the intent and the content of our management systems
Our ongoing commitment will assist us to achieve our targets and the outcomes as identified above, with an aim of best practice followed at all times. We strongly believe in empowering people and working together.
Our Quality Policy, is available to Consumers via our website and also displayed in our reception area.