Clinical safety and quality indicators 

Ramsay Health Care aims to provide safe, high-quality and evidence-based care. We measure and monitor key clinical indicators to identify areas for improvement and help maintain patient safety.

We aim to help you understand what to expect during your hospital stay. We believe in partnering with our patients so they can play an active role in making any plans or decisions regarding their treatment. If you ever have a question about your care, we encourage you to ask. 

We prioritise patient health and safety in every aspect of care and regularly assess our performance against national standards. We monitor clinical indicators and apply evidence-based strategies to support safety, reduce risks and identify areas for improvement. We also focus on key patient risk areas, as outlined on this page. 

Open disclosure 

Ramsay Health Care makes every effort to minimise risk to our patients. Unfortunately, incidents can occur – and when they do, we investigate and discuss with you what has happened. This is called open disclosure. Open disclosure is an honest discussion with patients and families if an incident results in unintended harm. It is an investigation of what happened and, where possible, taking action to prevent similar incidents in the future.  

 Download this pamphlet to learn more about open disclosure. 

Patient identification and information sharing 

Sharing information about your care while you are in hospital is an important aspect of ensuring your safety and the continuity of your care between your doctor, nurse and other health care workers. Every day, at the start of a shift, our staff does a handover. This process includes staff coming to your bedside to introduce themselves and discuss your care. This is an opportunity for you, your family or your carer to ask questions, clarify concerns and take an active role in your care. This can also be a good time to discuss your discharge plan. 

Checking your hospital identification band

You will be given an identification band when you are admitted to hospital. Staff may refer to it as an 'ID band' or a 'wrist band'. It will include your name and date of birth and be placed on your wrist, leg or both prior to your procedure.   

You should:  

• Always wear your ID band.
• Make sure the information on your ID band is correct. 
• If you have any allergies, check that you have a red ID band.

A member of staff will check your ID band before any test or procedure, or before giving you medication. They will also ask for your name and confirm some personal details to make sure that the right patient gets the right treatment.  Every member of Ramsay hospital staff should be wearing an identification badge. If you can't see a staff member’s badge, or if you're not sure who someone is, please ask. 

Hygiene and infection indicators

We aim to minimise the risk of infection to patients, staff and visitors that come to our hospitals. Our infection rates have been consistently below the industry benchmark.

What Ramsay Health Care does to reduce your infection risk 

Ramsay Health Care has programs to detect and prevent infections that are common within health care environments. We have signs to encourage visitors to Ramsay hospitals to use antiseptic hand rub, which is located throughout our facilities.

What you can do to reduce your infection risk 

There are several ways you can assist in preventing infections:  

• Always wash your hands after using the toilet, bedpan or a commode.

• Wash or clean your hands before eating.

• Don’t be concerned about asking your doctor or staff caring for you if they have performed hand hygiene.

• Avoid touching your wound or any devices you might have (for example, fluid or drain tubes).

• Tell our staff if your wound or the areas around any lines or tubes become red, swollen or painful.

• Discourage visitors who might be feeling unwell.

• Stop smoking before any surgery, as smoking increases your risk of infection.  

One of the most effective ways to prevent infection spreading among patients is for all health professionals to perform hand hygiene. At Ramsay, hand hygiene is conducted in accordance with the Five Moments framework. Five Moments is a simple method for remembering some of the key times a health care worker’s hands should be cleaned: before touching a patient, before a procedure, after a procedure, after touching a patient and after touching a patient’s environment. 

Ramsay Health Care participates in the national hand hygiene strategy through the Australian Commission on Safety and Quality in Health Care (ACSQHC). We conduct hand hygiene audits three times per year. Hand hygiene compliance is reported as the percentage of correct moments from all observed moments. 

Staphylococcus aureus bacteraemia (SAB) or blood stream infections are a risk to patients both in the hospitals and the community. Infection prevention and control (IPC) programs are designed to minimise risk of these infections occurring as part of standard precautions and aseptic technique practices. Health care facilities actively monitor for SABs as part of the facility and organisations infection surveillance programs.  

The rate of SAB infections in a hospital is an indicator of the effectiveness of its infection prevention and control program. It is a key indicator for acute hospitals and is reported nationally. 

The SAB indicator is reported as a rate of infections per 10,000 patient days. It is calculated by dividing the number of SAB infections that meet the indicator criteria by the number of patient days, then multiplying that figure by 10,000. 

Surgical site infections are an indicator for monitoring the number of infections that occur after an operation. They are not necessarily caused by the operation itself and are not always preventable (for example, in the case of a perforated bowel). Prophylactic antibiotics are sometimes prescribed to reduce the risk of surgical infections.  

Ramsay Health Care participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for these indicators.  

Surgical site infection rates are tracked across all Ramsay hospitals and submitted to the ACHS Clinical Indicator Program. The charts below show rates for knee and hip prosthesis infections, compared to the industry average.

Data is presented as the percentage of procedures resulting in infection. Lower rates are better. These results help inform quality improvement initiatives across all facilities.

Unplanned admissions and return to theatre indicators 

Ramsay Health Care has a low percentage of patients who have an unplanned readmission to hospital following discharge. Monitoring this information is very important, as it provides an indication of the effectiveness of our discharge planning processes and the risk of a patient developing complications after they have gone home. However, there are many factors which can contribute to an unplanned readmission and sometimes this cannot be prevented.

What Ramsay Health Care does to optimise surgical outcomes 

Ramsay Health Care doctors perform surgery in many specialty areas, which range from minor procedures to more complex surgery requiring specialised care. We monitor our patient outcomes by comparing the number of unplanned returns to theatre for patients at Ramsay hospitals to those of patients at other Australian hospitals. The aim is to reduce returns to theatre wherever possible; however, there are many factors which can influence this and sometimes a return to theatre is essential.  

Unplanned returns to the operating theatre are frequently due to complications, for example, treating bleeding or other problems which can occur early after an operation. Complications after complex surgery are sometimes expected due to a patients’ pre-existing diseases or condition or the nature of the disease or condition being treated. Ramsay hospitals monitor all unplanned returns to theatre and implement quality measures aimed at supporting recovery and improving patient outcomes.  

Many patients are treated in an intensive care unit (ICU), as they are recognised as being at high-risk and in need of specialised monitoring and management. An unplanned admission to the ICU could indicate that a patient requires a higher level of care than was anticipated. Ramsay hospitals monitor all unplanned admissions to the ICU and implement quality measures required to support recovery and improve patient outcomes.

The ‘unplanned readmissions within 28 days’ indicator is reported as a percentage of the number of patients requiring an admission during the period. It is calculated by dividing the events that meet the indicator criteria by the number of patients being admitted during the period.  

The ‘unplanned return to theatre indicator’ is reported as a percentage of the number of patients having a procedure during the period. It is calculated by dividing the events that meet the indicator criteria by the number of patients having a procedure during the period.  

The ‘unplanned admission to ICU’ indicator is reported as a percentage of the number of patients receiving anaesthesia care during the period. It is calculated by dividing the events that meet the indicator criteria by the number of patients receiving anaesthesia care during the period. 

Pressure injuries 

Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and can cause significant pain and discomfort, which can result in a slower recovery. 

What Ramsay Health Care does to reduce your risk of pressure injuries

Pressure injuries are also known as pressure ulcers and can happen very quickly if you are unwell or not able to move easily. Ramsay Health Care's facilities are well-resourced with the latest equipment to assist staff in preventing pressure injuries. Patients are also risk-assessed on admission using an evidence-based tool. If a patient is found to be at higher risk of developing pressure injuries, Ramsay staff then follow a care plan, which is designed to minimise that risk. This includes inspecting the patient’s skin frequently, keeping their skin dry and managing any moisture, optimising their nutrition and hydration, moving the patient frequently and even using special pressure-relieving mattresses. 

What you can do to reduce your risk of a pressure injury 

Any form of pressure or rubbing can cause skin damage, particularly if your skin is moist or if you suffer from poor circulation or sensation. 

You can help decrease your risk by: 

• Telling a nurse if you have any pain or burning feelings in your skin.
• Keeping active however you can (for example, changing positions, turning from side to side to relieve pressure on your bottom and heels, and moving as much as possible).
• Eating a variety of foods and drinking plenty of fluids.
• Avoiding wrinkled, damp clothes and bedding – alert a staff member if you need new linens.
• Asking a staff member to raise the foot of your bed so you don’t slide down (which can put pressure on your bottom, heels and elbows).
• Sitting in a chair to eat instead of in bed (if permitted).
• Avoiding smoking, as it can reduce the blood flow to your skin. 

The pressure injury indicator is reported as a percentage of all patient days during the period. Ramsay Health Care participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for this indicator. It is calculated by dividing the number of patients who develop a pressure injury and meet the indicator criteria by the number of days for all patients who were admitted. 

Medications 

Medicines are commonly used in health care settings to treat a variety of conditions, so it is important to measure the risk of errors. Ramsay Health Care facilities report  rates of medication errors that are below national benchmarks. These results reflect the safety strategies in place across our hospitals and our commitment to ongoing monitoring and improvement.

What Ramsay Health Care does to reduce your medication risk 

Ramsay Health Care takes all medication errors very seriously. We encourage staff to report all medication errors as incidents, no matter how minor they might seem. All medication incidents are investigated and actioned. Any serious medication incidents are investigated thoroughly and monitored by Ramsay’s National Clinical Governance Unit.

In addition, Ramsay Health Care has medication administration policies and processes in place which have been developed using best practice principles. 

The Australian Commission on Safety and Quality in Health Care has introduced safety initiatives for medication administration and reconciliation and Ramsay Health Care has adopted these strategies. This includes the National Inpatient Medication Chart, which standardises the documentation on how medicines are prescribed and ordered. Ramsay’s adoption of the User-Applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered. 

What you can do to reduce your medication risk 

We encourage you to be involved in the management of your medicines. If you have any concerns or questions, please discuss them with your doctor, pharmacist or nurse. 

It is important during your stay that we know what medicines you are taking. Our doctors, pharmacists and nurses will ask you about the medications you take at home, including any complementary or alternative therapy medicines. This could include vitamins, nutritional supplements, homeopathic remedies, Chinese or Ayurvedic treatments, or traditional Aboriginal or Torres Strait Islander medicines.  

It is important you advise our staff of any allergies you have experienced or reactions to medicines you have had in the past.   

The serious medication error indicator is reported as a percentage of all patient days during the period. Ramsay Health Care participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for this indicator. It is calculated by dividing the number of patients who require medical intervention as a result of a medication safety incident by the number of days for all patients who were admitted. 

Falls

Your risk of falling increases with age, with data suggesting that one-third of people over the age of 65 years have one or more falls a year. Falls can occur at all ages but the frequency and severity of fall-related injuries increases significantly with age. These injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. Such injuries can result in hospitalisation or an increased length of stay in hospital.  

The risk of falling can greatly increase when admitted to hospital due to a range of factors, including illness and unsteadiness, adapting to a new environment, starting a new medication or walking in unsafe footwear or slippers. 

What Ramsay Health Care does to reduce your falls risk 

We use evidence-based strategies to reduce the risk of falls and monitor falls data across all hospitals to guide improvement. Falls are monitored both by the total number of falls in our hospitals (shown as Inpatient falls) and the number of falls that result in a serious outcome such as a fracture or closed head injury (shown as Serious falls).

Our strategies to prevent falls include: targeted hourly rounding of patients identified as being at high risk of falling, ensuring that call bells and personal items are within patient reach, answering call bells promptly and regularly assisting patients to the toilet. In addition, Ramsay Health Care has purchased low beds, falls mats and patient alarms to further decrease the potential for any fall injury. 

What you can do to reduce your falls risk 

Falls can be a major cause of injury. We aim to reduce the risk of falls during your hospital stay, and you can support this by following some practical steps:

• Become familiar with your surroundings.
• Learn how your bed controls work and how to use the call bell – if you can't reach it, ask your nurse to move it closer.
• Ask your nurse to adjust the bed height if needed.
• Use the call bell whenever you need help.
• Wear supportive, flat, non-slip shoes – avoid walking in socks or pressure stockings.
• Keep glasses, hearing aids, and mobility aids within reach – use the call bell to ask staff for help.

Falls indicators are reported as a percentage of all patient days during the period. Ramsay Health Care participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for these indicators. The indicators are calculated by dividing the number of inpatient falls that meet the indicator criteria by the number of days for all patients who were admitted. 

Blood safety 

Australia has one of the safest blood supplies in the world. However, as with any medical procedure, a blood transfusion is not completely free from risk. A blood transfusion is a procedure where you receive blood through an intravenous cannula (IV) inserted into one of your veins. 

What Ramsay Health Care does to reduce your blood safety risk 

Before you receive a blood transfusion, two members of staff will perform strict checks of your name and date of birth. If you need to have more than one bag of blood, staff will do these checks every time. While you are having your transfusion, staff will also monitor your pulse, blood pressure and temperature on a regular basis. Most people feel no different while having a transfusion but if you feel unwell tell a member of staff immediately. 

What you can do to reduce your blood safety risk 

Any treatment is a choice and before you are given a transfusion, you will be asked for your consent. To help you make this choice, the following questions might be helpful: 

• Do you know why a transfusion has been recommended? 

• Have you asked about ways to avoid or reduce the need for a transfusion? 

• Do you understand the risks?  

More common risks of transfusion include minor reactions, like a mild temperature or skin rash 

The serious blood transfusion events indicator is reported as a percentage of all transfusion episodes during the period. Ramsay Health Care participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for this indicator. It is calculated by dividing the number of patients who have a serious blood transfusion event that meets the indicator criteria by the number of transfusion episodes during the period. 

Rehabilitation indicators 

Rehabilitation programs aim to help people increase or recover their strength, ability and independence after an injury, disease or surgery. At the time of their admission into a rehabilitation program, a patient has their functional independence measure (FIM) rating assessed by a qualified member of the rehabilitation team. Their FIM is reassessed during, and at the end, of the program to measure the patient’s functional improvement and their increased independence in daily life. Increased ability in social interaction and psychological wellbeing is also measured. FIM is the industry-standardised functional assessment tool that is used by all Ramsay rehabilitation hospitals to measure this information. A higher score indicates that the patient has achieved a higher level of improvement in all of the areas being measured. Ramsay rehabilitation hospitals have achieved higher than industry average scores for functional improvement. 

Coming to hospital for obstetric and maternity care 

When a baby is born at a Ramsay maternity hospital, we complete an Apgar score check at one minute after birth and again at five minutes after birth. Apgar is a simple assessment of a baby’s condition, which helps determine if they need additional medical assistance. A midwife or doctor checks the baby’s heart rate, breathing effort, muscle tone, reflex irritability and skin colour. Each of these is rated from zero to two and the sum of those five ratings makes up the baby’s total Apgar score. The Apgar score scale ranges from 1 to 10, with a score of 7 or above considered normal (which means the baby doesn’t require any additional medical intervention). The graph below shows the percentage of healthy babies born with normal Apgar scores. This is very similar to the industry average.  

Sometimes during a vaginal birth, a vaginal tear can occur.  The indicator for surgical repair for fourth-degree vaginal tears is an indicator used to monitor the safety of maternal care. Ramsay Health Care participates in the Australian Council on Healthcare Standards (ACHS) Clinical Indicator Program and use their definitions for these indicators.  

The Apgar indicator is reported as a percentage of births. The indicator for surgical repair of a fourth-degree tear is reported as a percentage of women giving birth for the first time. They are calculated by dividing the events that meet the indicator criteria by the number of babies born (Apgar) or women giving birth for the first time (tears) during the period. 

Coming to hospital for mental health care 

Ramsay Health Care assesses mental health outcomes using two internationally recognised tools: the Health of the Nation Outcome Scales (HoNOS) and the Mental Health Questionnaire (MHQ-14). HoNOS measures clinician-observed changes in health and social functioning. MHQ-14 is a patient-reported scale that captures symptoms such as fatigue, anxiety and depression, and their impact on daily life.

View the latest HoNOS and MHQ-14 results for Ramsay hospitals below (April to June 2024).