NSQHS Standards

At FOCUS Eye Centre we implement the National Safety and Quality Health Service NSQHS Standards

The Australian Commission on Quality and Safety in Healthcare has developed 10 NQSHS Standards to improve the quality and safety of healthcare in Australia. The NSQHS Standards provide a nationally consistent framework for the level of care consumers can expect from health services.

The Directors and staff at FOCUS Eye Centre are committed to providing care consistent with the NQSHS standards. As part of our Quality Assurance Program we undertake activities to demonstrate and monitor quality outcomes.

Further Information regarding the NQSHS standards www.safetyandquality.gov.au

Quality outcomes by year

Quality Outcomes for 2016

QUALITY PROGRAM OUTCOMES and Accreditation 2016

Focus Eye Centre is an accredited and licenced Day Procedure Centre and Specialist Ophthalmic Practice.

What is Accreditation?

Accreditation is independent recognition that an organisation meets the requirements of defined criteria or standards.

At Focus Eye Centre we run a Quality Management System to meet the requirements of AS/NZ ISO 9001 and the (NSQHS) National Safety and Quality in Healthcare Standards.

Focus Eye Centre is independently audited every year against these criteria to maintain ongoing accreditation.

Our Quality outcomes for 2016 include:

Patient Satisfaction and Partnering with Consumers

We collect ongoing feedback from patients via surveys and satisfaction questionnaires. This information is presented and discussed at Quality Improvement Committee meetings attended by doctors and staff. Improvements are made as a result.

Some Improvements made in 2016 were:

  • An issue was raised by a patient concerned about receiving anaesthetic risk information verbally a few moments prior to their surgery. We carried out a review of this procedure, in consultation with visiting Anaesthetists, and the patient. An anaesthetic information handout was developed. This is provided at time of booking. The handout describes possible risks and fasting instructions and allows patients greater opportunity to ask questions prior to their procedure.
  • Patients have been concerned about waiting times and not being informed of delays. All staff have been made aware of the importance of communicating waiting times to reduce anxiety in patients having surgery. There is an ongoing monitoring of waiting times and a review of how we communicate this to patients.
  • We have simplified Cataract surgery eye drop instructions, as some patients were confused with the protocol. The frequency was streamlined with all drops used 4 times per day. Sample charts were devised charts and patient preferences were determined. No further issues have arisen.

We appreciate and seek ongoing feedback from our patients. Feedback forms are available in the waiting room at Kingsford and Double Bay and on the website. The Centre has implemented information in line with the Australian Charter of Healthcare Rights. Copies are available in the waiting room and booking office. 

Preventing and Controlling Health Associated Infections

Maintaining a high standard of Infection Prevention is our priority.

In 2016, 1460 procedures were carried out in our Theatre suite.

There were no infections reported following Cataract surgery.

One infection occurred following intravitreal injection. The patient has recovered and recommenced treatment.

Falls Prevention

In 2016 there were no falls reported within the Centre.

Medication Safety

The Centre has implemented a medication safety management system in line with the NSQHS standards.

There were no medication errors reported in 2016.

A medication safety Audit was carried out with 100% compliance.

Additional Reporting

A risk management approach is taken to all incidents, accidents, complications, compliments and complaints occurring at the Centre. Issues are reported and addressed at Quarterly Quality Improvement meetings.

The Centre participates in ACHS Clinical Indicator reporting. Comparison of results is across a wide range of participating hospitals and day procedure centres. We continue to have low rates and compare favourably to other centres.

As members of an Ophthalmic Benchmarking group we compare results with similar Day Surgery Centres in Infection Rates and Infection Control, Falls incidence and Risk Management. Copies of Audits carried out are available on request.

In 2016 all incidents were managed and any complaints were resolved by management.

Staff Education and Presentations

The Centre has an ongoing commitment to education and training.

In 2016 staff received training in line with the requirements of the NSQHS standards including firefighting and evacuation, manual handling, infection control, hand hygiene, open disclosure, patient centred care and medication safety.

Our Doctors and staff continue to participate in continuing professional development and have provided presentations at International and Australian conferences and meetings during 2016.

Further Information regarding the NQSHS standards www.safetyandquality.gov.au

Quality Program for 2015

In April 2015 the Centre underwent an external periodic review of Standard 1 Governance For Safety and Quality in Health Service Organisations, Standard 2 Partnering with Consumers and Standard 3 Preventing and Controlling Healthcare Associated Infections, as part of our ongoing Accreditation. The Centre was granted Accreditation having “Satisfactorily Met” all applicable standards and was awarded “Met with Merit” for one item.
As part of our Quality Program we undertake activities to demonstrate and monitor quality outcomes identified to improve Safety and Quality in Healthcare.

Our Quality outcomes for 2015 include:

Patient Satisfaction and Partnering with Consumers

Feedback is collected via Satisfaction Survey. These are distributed to all Day Surgery patients. The results are presented and discussed at Quality Improvement Committee meetings attended by doctors and staff.

Ongoing feedback is sought from patients regarding information provided, access and infection control.
Improvements are made as a result of patient and community feedback.

Some Improvements made in 2015 were:

  • We changed our process so that all patients take their drops home following surgery. Administration staff fix patient labels to eye drop bags which are placed in the surgical file. This was changed to ensure all patients receive the correct eye drops and instructions.
  • Following further feedback about parking availability at Kingsford we reviewed arrangements by:
    • Updating our WEBSITE to include information about car parks at each Centre.
    • Reviewing consultation appointment letter to provide information about our website.
    • Relevant parking info is displayed at reception both sites.
    • Training of staff to provide Information about parking options.
  • To clarify costing for consultations information is displayed at reception to inform patients that fees are charged for additional testing.

We appreciate feedback. Feedback forms are available in the waiting room at each site and on the website. The Centre makes available to patients information about the Australian Charter of Healthcare Rights. Copies of the Charter are available in the waiting room and in the booking office.

Preventing and Controlling Health Associated Infections

Maintaining a high standard of Infection Prevention is our priority. In 2015, 1432 procedures were carried out in our Theatre suite. There were no infections reported following Cataract surgery. One infection occurred following intravitreal injection, and 2 cases following other procedures. All patients have recovered following treatment.

Falls Prevention

In 2015 there were no falls reported within the Centre.

Medication Safety

The Centre has implemented a medication safety management system in line with the NSQHS standards.

  • There were no medication errors reported in 2015.
  • A medication safety Audit was carried out with 100% compliance.

Additional Reporting

A risk management approach is taken to all incidents, accidents, complications, compliments and complaints occurring at the Centre.

Any issues raised are reported and addressed at Quarterly Quality Improvement meetings or by the Directors and Governing Body if needed.

The Centre participates in ACHS Clinical Indicator reporting. Comparison of results is across a wide range of participating hospitals and day procedure centres. We continue to have low rates and compare favourably to other centres.

As members of an Ophthalmic Benchmarking group we compare results with similar Day Surgeries Centres in Infection Rates, Falls resulting in harm to the patient, Risk Management and Infection Control. Copies of Audits carried out are available on request.

In 2015 all incidents were managed and any complaints were resolved by management.

Staff Education and Presentations

The Centre has an ongoing commitment to education and training

In 2015 the Centre arranged training for staff in firefighting and evacuation, manual handling, infection control, hand hygiene education, open disclosure, patient centred care and medication safety.

Our Doctors and staff continue to participate in continuing professional development and have provided presentations at International and Australian conferences and meetings during 2015.

Further Information regarding the NQSHS standards www.safetyandquality.gov.au

Quality Program for 2014

In April 2014 the Centre was underwent an independent Re-Certification Audit having implemented all applicable NSQHS Standards. Standard 7 Blood and Blood Products is not applicable to our Centre.

The Centre was granted Accreditation having Satisfactorily Met all applicable standards and was awarded Met with Merit for one item.

As part of our Quality Program we undertake activities to demonstrate and monitor quality outcomes identified to improve Safety and Quality in Healthcare.

Our Quality outcomes for 2014 include:

Patient Satisfaction and Partnering with Consumers

Feedback is collected via Satisfaction Survey collected from all Day Surgery patients, presented and discussed at Quality Improvement Committee meetings attended by doctors and staff. Ongoing feedback is sought from patients regarding information provided, access and infection control.

Improvements are made as a result of patient and community feedback.

Some Improvements from 2014 were

  • Improvement waiting times for patients having Intravitreal injections.
  • Improved information about parking options available at Kingsford and Double Bay and training to ensure booking staff are aware to inform all patients of parking options when booking appointments.
  • Change of email address for Surgical bookings to ensure Surgical Information emails were not going to SPAM.
  • Using ongoing feedback to improve and clarify information provided to patients having surgery.
  • Improved patient information for EXCIMER Laser procedures including a more descriptive explanation of what patients may experience after surgery.
  • Following a patient suggestion music is played in the waiting room at Double Bay

We appreciate consumer feedback. Feedback forms are available in the waiting room and on the website. The Centre has implemented Information about patient Rights in line with the Australian Charter of Healthcare Rights. A copy of this is in the waiting room and booking office.

Preventing and Controlling Health Associated Infections

The Centre has maintained a high standard of Infection control with no infections reported in 2014.

Falls Prevention

In 2014 there were no falls reported within the Centre.

Medication Safety

The Centre has implemented a medication safety management system in line with the NSQHS standards.

  • There were no medication errors reported in 2014.
  • A medication safety Audit was carried out with 100% compliance.

Additional Reporting

  • A risk management approach is taken to all incidents, accidents, complications, compliments and complaints occurring at the Centre. Issues are reported and addressed at Quarterly Quality Improvement meetings.
  • The Centre participates in ACHS Clinical Indicator reporting. Comparison of results is across a wide range of participating hospitals and day procedure centres. We continue to have low rates and compare favourably to other centres.
  • As members of an Ophthalmic Benchmarking group we compare results with similar Day Surgeries Centres in Infection Rates, Falls resulting in harm to the patient, Risk Management and Infection Control. In 2014 our results appear below.
SAFETY AND QUALITY INDICATOR FOCUS EYE CENTRE RESULTS BENCHMARKING GROUP AVERAGES
Infection rates 0.00% 0.05%
Fall resulting in harm 0.00% 0.00%
Risk Management 98% 99.7%
Infection Control 98% 95%
  • In 2014 all incidents were managed without adverse outcome and any complaints were resolved by management.
  • Copies of Audits carried out are available on request.

Staff Education and Presentations

The Centre has an ongoing commitment to education and training

In 2014 staff had training on CPR firefighting and evacuation, manual handling infection control, hand hygiene education, open disclosure, patient centred care and medication safety.

Our Doctors and staff continue to participate in continuing professional development and have provided presentations at International and Australian conferences and meetings during 2014.

Further Information regarding the NQSHS standards www.safetyandquality.gov.au

Quality Program For 2013

Our Quality outcomes for 2013 include:

Patient Satisfaction and Partnering with Consumers

Satisfaction surveys are collected from all Day Surgery patients. Feedback is presented at Quality Improvement Committee meetings attended by doctors and staff. Ongoing feedback is sought from patients regarding information provided, access and infection control.

Improvements are made as a result of patient and community feedback.

Some Improvements from 2013 include:

  • Arrival times for surgery were reviewed to decrease waiting times prior to surgery and improve patient comfort.
  • Procedures implemented to enable paperwork and payment to be carried out prior to the day of surgery if requested.
  • Inclusion of the eye drop chart with post op information and medication chart for Nursing Home Residents, with positive feedback gained from Nursing home staff.
  • Access and safety to Kingsford Centre improved with completion of the footpath in front of the building.
  • Ongoing feedback continues to improve and clarify information provided to patients having surgery. We have updated our information for cataract patients on hand washing, use of eye drops and infection control.
  • We offer Cataract information in Greek and Chinese as requested. Staff speak a range of languages including Greek Chinese French and Arabic.
  • Pre op information available on our website.

We appreciate consumer feedback. Focus Eye Centre has implemented Information about patient Rights in line with the Australian Charter of Healthcare Rights. A copy of this is in the waiting room.

Preventing and Controlling Health Associated Infections

Infection prevention and control is one of the most important considerations in eye surgery. Focus Eye Centre has maintained a high standard of Infection control with no infections occurring following Cataract Surgery, and one infection occurring overall during 2013.

Falls Prevention
  • In 2013 there were no falls reported within the Focus Eye Centre.
Medication Safety

Focus Eye Centre has implemented a medication safety management system in line with the NSQHS standards.

  • There were no medication errors reported in 2013.
  • A medication safety Audit was carried out with 97.6% compliance. All areas have since been addressed including staff training in this area.
Additional Reporting
  •  A risk management approach is taken to all incidents, accidents, complications, compliments and complaints occurring at Focus Eye Centre. Issues are reported and addressed at Quarterly Quality Improvement meetings.
  • Focus Eye Centre participates in ACHS Clinical Indicator reporting. Comparison of results is across a wide range of participating hospitals and day procedure centres. We continue to have low rates and compare favorably to other centres.
  • As members of an Ophthalmic Benchmarking group we compare results in Adverse events, Patient Satisfaction, Risk Management and Infection Control with similar Day Surgeries Centres. In 2013 our results were in line with or better than our peers.
  • In 2013 all incidents were managed without adverse outcome and any complaints were resolved by management.
Staff Education and Presentations

Focus Eye Centre has an ongoing commitment to education and training.

In 2013 all staff attended CPR Fire fighting and manual handling infection control and hand hygiene education.

Our Doctors and staff continue to participate in continuing professional development and have provided presentations at  International and Australian conferences and meetings during 2013.

Further Information regarding the NQSHS standards www.safetyandquality.gov.au

Quality Program For 2012

Our Quality outcomes for 2012 include:

Patient Satisfaction and Partnering with Consumers

Satisfaction surveys are collected from all Day Surgery patients. Feedback is presented at Quality Improvement Committee meetings attended by doctors and staff. Ongoing feedback is sought from patients regarding information provided, access and infection control.

Improvements are made as a result of patient and community feedback.

Some Improvements from 2012 include:

  • Post op instructions to the carer now given in private.
  • Improved facilities for storage of patient belongings in theatre pre and post op.
  • Frosted highlight panels at eye level installed on entry doors at Kingsford to improve visibility of glass.
  • In response to patient suggestions the Centre is in the process of installing a sign for the patient toilet at Kingsford.
Preventing and Controlling Health Associated Infections
  • Infection prevention and control is one of the most important considerations in eye surgery. We maintain a high standard of Infection Control at Focus, with no infections reported from the centre in 2012
Falls Prevention
  • In 2012 there were no falls reported within the Centre.
  • Management is, however working with Randwick Council to rectify the footpath outside the Kingsford Day Surgery as this has proved to be a hazard for 2 patients entering and leaving the Centre.
Additional Reporting
  • A risk management approach is taken to all incidents, accidents, complications, compliments and complaints occurring at the Centre.
  • These are reported and addressed by the Quality Improvement Committee. and improvements made.
  • In 2012 all incidents were managed without adverse outcome and any complaints were resolved by management.
Staff Education and Presentations:
  • The Centre has an ongoing commitment to education and training. In 2012 all staff attended CPR Fire fighting and manual handling infection control and hand hygiene education.
Presentations given by Doctors and staff in 2012 included:
  • Dr Richard Smith Reasons for using Acrysof IOLs
  • Dr Margaret Kearns Laser Refractive Surgery
  • Dr Con Petsoglou Corneal Infections , Implications Use of surgical glue and Mitomycin – C
  • Dr Paula Berdoukas Fascinating Field Tests
  • Ana Alexandratos Infection Control and aseptic Technique

QUALITY COMMENTS

If you would like further information on our Quality Program or to comment on our Quality Outcomes, please visit us on Facebook.

To contact our Quality Manager, Sally Turner via email click here, or call her on 02 9663 3927

QUALITY FEEDBACK

At Focus we are committed to providing a high standard of care and meeting the needs of our patients. We appreciate and welcome your feedback!

Fill out our survey here

Survey forms are also available in the waiting area.