QUALITY PROGRAM OUTCOMES and Accreditation 2018
Focus Eye Centre is an accredited Day Procedure Centre and Specialist Ophthalmic Practice. We are licenced by the NSW Ministry of Health and specialise in providing Medical and Surgical Eye care services. We are constantly reviewing and improving our processes to meet the needs of our patients. We invest in our staff and in the latest technology and equipment available.
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 the (NSQHS) National Safety and Quality Health Service Standards.
To maintain accreditation Focus Eye Centre is independently audited against these criteria every 3 years.
Our Quality outcomes for 2018 include:
Patient Satisfaction and Partnering with Consumers
Ongoing feedback is collected from patients via surveys and satisfaction questionnaires. This information is presented and discussed at Quality Improvement Committee meetings attended by doctors, staff and consumer appointed representative, who provides a patient perspective to the committee. Improvements are made as a result of issues discussed.
In 2018 a consumers provided input resulting in a number of improvements to our processes.
- A patient reported that they were receiving inconsistent information from Staff and Doctors regarding when activities can be resumed post Cataract Surgery. A list of common activities and time frame for when they can be commenced was developed. This was circulated to staff and is provided in the PRE OP pack.
- Patients found that their eye was not being secured under the patch. This lead to the steri-strip being placed horizontally across the lashes to better secure the eye.
- A review of information format was also carried out as our consumer representative felt that a booklet format may be easier than A4 information. Following this review patients had no preference for either format, but they liked the folder given. No changes were implemented.
Feedback forms are available in the waiting room at Kingsford and Double Bay and on our website. We aim to address the needs of all patients and carers attending the Centre. Staff speak a range of languages including Chinese, Greek, Vietnamese and Polish. We embrace our multicultural diversity. Pre and post-operative Cataract surgery information is also available in Chinese and Greek. Patients can also access information via our website. The Centre has implemented information in line with the Australian Charter of Healthcare Rights. Copies are available in the waiting room, booking office and on our website.
Preventing and Controlling Health Associated Infections
Maintaining a high standard of Infection Prevention is our priority.
In 2018 1647 procedures were carried out in our Theatre suite.
832 Cataract surgery procedures were carried out with no resulting infections.
537 Intravitreal Injection treatments for Macular Degeneration were carried out with one infection resulting. Our rates are comparable with infection rates experienced at other eye Centres. We continue to monitor and improve our processes to eliminate infections.
A hand hygiene program has been implemented to monitor and improve compliance for staff and Doctors in hand hygiene. Our Antimicrobial Stewardship program looks at the use and prescription of antibiotics, in line with approved prescribing guidelines. This program aims to reduce Antimicrobial Resistance.
In 2018 there were no falls reported for patients attending the Centre.
The Centre has implemented a medication safety management system in line with the NSQHS standards.
There were no medication errors reported in 2018.
A medication safety Audit was carried out with 100% compliance.
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 2018 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 2018 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 conferences and meetings both in Australia and overseas during 2018.
Further Information regarding the NQSHS standards www.safetyandquality.gov.au