Patient Safety and Quality

Our Commitment to Patient Safety and Quality

Oxford Day Surgery is committed to providing the highest quality healthcare, with a core focus on each patient’s experience. Achieving the best outcomes for patients in a safe, caring and friendly environment is reflected in our day-to-day operations, corporate and clinical governance, values and workplace culture.

We are owned and operated by National healthcare provider, Montserrat Day Hospitals and utilise their robust Quality Management System (QMS) and framework to manage the care and services we provide.

The Montserrat Day Hospital QMS is designed to monitor care outcomes, patient satisfaction and safety initiatives, manage and mitigate risks, and identify training requirements for our staff across the National Safety and Quality Health Service Standards. This system is supported by continual investment in state-of-the-art medical equipment and a highly skilled team of clinicians, nurses and support staff. All Montserrat hospitals perform various audits for compliance as per our accreditation and licensing requirements.

At Oxford Day Surgery our Quality scorecard includes:

  • Patients’ experience and feedback
  • Hand hygiene compliance rates
  • Surgical site infections
  • Fall rates
  • Medication safety
  • Unplanned returns to theatre

At all times we uphold the National Safety and Quality Health Service Standards (NSQHS). Learn more about our approach to the National Standards below and how we utilise our QMS and framework as we strive to be leaders in the provision of quality healthcare.

Oxford’s Approach to the Eight National Safety & Quality Health Service Standards

At Oxford Day Surgery, we take our responsibility to the community very seriously. We gather important data across all aspects of our hospital to continuously improve the safety, effectiveness and quality of our services. Delivering quality, patient-focused healthcare is our commitment and our management across all levels of the organisation use clinical governance systems to achieve, monitor and regularly review our safety and quality performance.

Our entire workforce at Oxford Day Surgery – nurses, clinicians, management, the board of Directors and support staff have accountability to patients and the broader community for ensuring the delivery of our healthcare is safe, effective, integrated, high quality and continuously improving.

Oxford Day Surgery partners with select consumers and patients as this has proven beneficial in the planning, design, delivery, measurement and evaluation of our healthcare facility. We place great importance on these partnerships as they help to guarantee quality patient outcomes and safety standards, whilst also benefiting patients’ carers and families, our clinicians and more broadly the healthcare industry. Partnerships have a positive effect on service planning, evaluating and development at our Day Surgery, and these partnerships exist across three levels:

  1. The relationship between Oxford’s clinician and patient at the point of care; a relationship founded on our values of respect, integrity, collaboration, innovation and compassion.
  2. Patients, carers, families and consumers involvement in planning, implementing and evaluating change at the department level at our facility.
  3. Consumers or patients’ involvement in the governance, policy and planning of our healthcare service, focusing on key areas like patient safety, facility design, quality improvement, patient or family education, staff education and training, ethics and research. Partnerships with the broader community may also occur at this level.

Oxford Day Surgery has robust systems in place to mitigate the risk of infection, foster good antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources.

We adopt a precautionary, proactive approach whilst upholding the highest standards in hygiene and cleanliness. We have high compliance rates of hand hygiene and a well-maintained facility that is optimised for patient flow. Our approach to preventing, controlling and responding to infections is well supported by the policies, processes and systems we have in place, creating a safe environment for patients, visitors and members of our workforce.

Medicines are the most widely prescribed treatment in healthcare and contribute significantly to improvements in patients’ health when used appropriately.

Accurately and safely prescribing, dispensing and administering the appropriate medicine to patients and monitoring medicine use is a mandatory standard at our Day Surgery. Our clinicians’ duty of care ensures patients and consumers are informed about and understand their individual medical needs, and associated risks.

Before commencing an episode of care, Oxford Day Surgery will source a patient’s best possible medication history and have this on record. Information relating to a patient’s allergies and adverse drug reactions is disclosed by the patient in our Health Assessment form before their admission.

Oxford Day Surgery provides continuous and collaborative care to patients in partnership with carers, families and all members of their healthcare team. Our hospital has integrated systems in place supporting our clinicians to deliver comprehensive, quality healthcare whilst mitigating and managing the risk of harm.

All clinicians at our Day Surgery undertake a screening and assessment process with patients to identify potential risks that could be associated with the delivery of healthcare. Patients, their carers and families are consulted as part of this process to develop goal-oriented, comprehensive care plans.

If a patient is at risk of harm, our clinicians will deliver targeted, best-practice strategies to prevent and manage this harm from occurring. Safely managing transitions between episodes of care, and ensuring a continuum of comprehensive care are standards our clinicians abide by.

One of the best ways we support coordinated and safe patient care as well as visitor and workforce safety is through effective communication and documentation. This encompasses communication with our patients, carers and families, multidisciplinary teams and clinicians, and all business units across our organisation.

Effective communication and documentation help to mitigate high-risk situations and manage patient safety. Oxford has formal processes in place to identify patients, match care to their needs, and appropriately manage clinical handovers when information about a patient’s care emerges or changes.

Whilst there are times when communication (be it informal) in the delivery of patient care will not be recorded, our Hospital’s approach is always to formalise the communication and documentation requirements critical to patient safety at key times during the delivery of care.

Oxford Day Surgery manages blood on an infrequent basis given the nature of our surgery and specialities. When required, we use a combination of clinical governance and quality improvement systems to appropriately manage a patient’s own blood, as well as any blood or blood products.

As part of the Montserrat Day Hospital group, we have strategies and procedures in place to accurately manage the availability and safety of blood and blood products. Safety systems are in place and every care is taken to safely administer blood products to each intended recipient, and closely monitor and report any adverse reactions or incidents. This dual approach to blood management and patient care is the most effective way to ensure the appropriate and safe use of blood and blood products at our hospital.

Clinicians, nurses and support staff at Oxford Day Surgery have a duty of care to recognise and promptly respond to changes in a person’s physiological, cognitive or mental state, otherwise known as acute deterioration. Providing patients with appropriate and timely care is part of our organisation-wide recognition and response system when acute deterioration is identified.

Early detection is critical in these situations as it may improve outcomes and lessen the intervention required when treating the patient. At Oxford Day Surgery we understand the importance of identifying and acting on the warning signs of clinical deterioration efficiently and appropriately. Management of these circumstances draws on our approach to comprehensive care and communication and documentation for safety.

Having a highly-skilled healthcare team who understand the signs and symptoms that could signal acute deterioration, combined with our safety, quality and patient monitoring systems all help to recognise acute deterioration.

Oxford Day Surgery’s Patient Safety & Quality Management System (QMS) Quarterly Report: January to March 2022

Oxford Day Surgery measures quality in many areas, by analysing and reporting on outcome and process measures, patient satisfaction and the hospital quality ranking.

Our core, quality principle is the continuous improvement of all processes and services supporting the care of patients. The Quality Management System (QMS) implemented across our hospital group, as previously defined allows us to deliver consistent and comprehensive care to our patients.

As part of the Montserrat Day Hospital group, Oxford Day Surgery monitors and reports on many quality measures including patient satisfaction surveys and the patient experience, infection prevention and control including hand hygiene compliance rates, patient incidents, medication safety, workforce training and compliance and return to theatre percentiles. The policies, processes, and procedures associated with these areas are embedded in all hospital operations and workflow.

Quality management focuses on continuous quality improvement as measured by consumer and patient satisfaction. Our quality structure is unique: it is integrated and further strengthened by our highly-trained nurses and medical staff.

Oxford Day Surgery’s Quality Measures

  • Patients Experience- Feedback
  • Infection Prevention
  • Monitoring incidents
  • Medication safety
  • Return to theatres monitoring

Patient feedback provides valuable information and not only ensures that patients’ voices are heard, but by examining patients’ feedback it gives direct insight into the quality of care and patient satisfaction.  This aids in maintaining and improving the standard of care offered at Oxford Day Surgery.  Patients are encouraged to provide feedback using the feedback form provided or by visiting our website.

Consumer satisfaction at Oxford Day Surgery has been collated and graphed for analysis.  The last quarter shows a 100% satisfaction rate, meaning all patients who were surveyed and provided feedback reported a positive experience at our Day Surgery.

Aside from patient feedback, Oxford has a formal complaints process should a patient be dissatisfied with the level of specialist care or customer service at our hospital. During the period January to March 2022, we cared for 1095 patients of which no complaints were received.

Consumer Satisfaction (Jan to Mar 2022)

Consumer Satisfaction 100%

Consumer experience (Jan to Mar 2022)

Across the Montserrat Day Hospital group, we incorporate high standard precautions for infection prevention and control including:

  • Hand hygiene
  • Use of Personal Protective equipment
  • Safe use of disposal consumable equipment
  • Reprocessing of medical equipment
  • Routine Cleaning

Oxford Day Surgery is currently reporting 90% compliance in hand hygiene with zero post-surgical infections for the January to March 2022 period. This is an excellent result highlighting the quality clinical care we provide in a safe environment.

Patient Outcomes - Post-surgical Infections (Jan to Mar 2022)

Safety reporting systems are a very important aspect of ensuring patient safety. Detecting near misses and incidents enables Oxford Day Surgery to improve practice and prevent any future adverse events. A near miss is an adverse event that has been intercepted and has not resulted in harm for example:

  • Slip or falls not resulting in injury
  • Medication error that has not resulted in harm (refer to Medication safety)
  • Pressure Injuries resulting in no harm

From a total of 1095 patients treated at Oxford Day Surgery during January to March 2022, there were no incidents of falls or pressure injuries.

Incidents of Falls
(Jan to Mar 2022)

Pressure Injuries
(Jan to Mar 2022)

Medication errors can have an impact on patient outcomes and can cause harm. Oxford Day Surgery’s medication safety systems are in place to prevent the occurrence of medical-related incidents. Staff are trained in the safe and appropriate use of medicines. 

Medication risks are described as errors in:

  • Prescribing
  • Administering and/or
  • Dispensing medication

We are pleased to advise there were no errors in the prescribing, administering and dispensing of medication at Oxford Day Surgery during January to March this year – the best possible outcome in medication safety.

Medication Safety (Jan to Mar 2022)

Surgical complication requiring the unplanned return to theatre within one month of a patient’s most recent discharge from hospital is classified as an Unexpected Return to Theatre. The return subjects the patient to repeated anaesthesia risks, which can be highly distressing and impact the patient and their family. Returning to the theatre generally occurs because the patient experiences one of the following:

  • Haemorrhage / bleeding
  • Wound reopening

The occurrence of unexpected return to theatre data from Oxford Day Surgery has been collated and graphed for analysis.  The last quarter report shows zero occurrences as a percentage during January to March 2022.

Unexpected Returns to Theatre (Jan to Mar 2022)