Sir John Monash Private Hospital has been registered with the Department
of Health in Victoria since 1992 and is fully accredited against the National Safety & Quality Health Services
Standards .

Safety & Quality

Our Philosophy is:
As a private hospital, our success will be directly related to the level of satisfaction we achieve in supplying services to the medical fraternity, their patients, and the environment within which our staff work. We believe that if we achieve this through efficient management, the needs of a ‘for profit’ private hospital will also be satisfied. Every member of staff contributes significantly either directly or indirectly to the quality of care we provide to our patients. Our staff will only be able to attain the high standards to which we aspire if they are well organised, work towards defined standards, have a clear sense of purpose and direction for the organisation and are encouraged and allowed to make a significant contribution to the setting of those standards. Whilst the organisational structure is divisionally defined on a functional basis, optimum results will be achieved by a team approach to client focused services. Managers at various levels throughout the organisation will be given responsibility and authority to plan and control the performance of their respective areas. Our business is medical hospitality. The hospitality aspect should help to distinguish the performance of this hospital from its peers and competitors in both public and private hospitals. The commercial success of the organisation depends on both efficient and effective management focus. We understand that new surgeons and new patients will be attracted to the Hospital because of the friendly atmosphere, and professional manner, and the Hospital’s reputation for excellence.

Our organisation is committed to child safety. We want children to be safe, happy and empowered. We support and respect all children, as well as our staff and volunteers. We are committed to the safety, participation and empowerment of all children. We have zero tolerance of child abuse, and all allegations and safety concerns will be treated very seriously and consistently with our robust policies and procedures. We have legal and moral obligations to contact authorities when we are worried about a child’s safety, which we follow rigorously. Our organisation is committed to preventing child abuse and identifying risks early, and removing and reducing these risks. Our organisation has robust human resources and recruitment practices for all staff and volunteers. Our organisations is committed to regularly training and educating our staff and volunteers on child abuse risks. We support and respect all children, as well as our staff and volunteers. We are committed to the cultural safety of Aboriginal children, the cultural safety of children from a culturally and/or linguistically diverse backgrounds, and to providing a safe environment for children with a disability. We have specific policies, procedures and training in place that support our leadership team, staff and volunteers to achieve these commitments.

Sir John Monash Private Hospital has a formal Medical Advisory Committee with representatives from our medical team, Director of Nursing & the CEO. The committee reviews clinical outcomes and excellence, addresses clinical compliance & has a strict protocol for credentialing and checking scope of practice for all medical practitioners.

Sir John Monash Private Hospital has a comprehensive Infection Prevention & Control program. Regular audits are performed to ensure we comply with the Australian Guidelines for Prevention & Control of Infections in Healthcare, AS/NZ4187:2014 & National Safety & Quality Health Services Standard.

Sir John Monash Private Hospital is committed to the National Hand Hygiene Initiative (NHHI) Australia program & conduct regular audits which align with the national average.

NHHI brochure_2019

Sir John Monash Private Hospital is committed to providing a high level of care by ensuring our staff receive training in the following.

  • Basic Life Support
  • Medication Safety
  • Clinical Deterioration
  • Manual Handling
  • Comprehensive Care
  • Communication
  • Fire Safety Training

Sir John Monash Private Hospital welcomes consumers to give us feedback. Feedback forms are available in recovery and reception. If you wish to be involved in our safety & quality program by reviewing data or contribute to our publications please contact the Director of Nursing.

AIM

When and if there is an adverse event at Sir John Monash Private Hospital, all personnel involved will be able to adhere to the principles of Open Disclosure as defined by the Australian Open Disclosure Framework.

PRINCIPLES OF OPEN DISCLOSURE

1. Open and timely communication

If things go wrong, the patient, their family and carers should be provided with information about what happened in a timely, open and honest manner. The open disclosure process is fluid and will often involve the provision of ongoing information.

  1. Acknowledgement

All adverse events should be acknowledged to the patient, their family and carers as soon as practicable. Health service organisations should acknowledge when an adverse event has occurred and initiate open disclosure.

  1. Apology or expression of regret

As early as possible, the patient, their family and carers should receive an apology or expression of regret for any harm that resulted from an adverse event. An apology or expression of regret should include the words ‘I am sorry’ or ‘we are sorry’, but must not contain speculative statements, admission of liability or apportioning of blame.

  1. Supporting, and meeting the needs and expectations of patients, their family and carer(s)

The patient, their family and carers can expect to be:

  • fully informed of the facts surrounding an adverse event and its consequences
  • treated with empathy, respect and consideration
  • supported in a manner appropriate to their needs.
  1. Supporting, and meeting the needs and expectations of those providing health care

Health service organisations should create an environment in which all staff are:

  • encouraged and able to recognise and report adverse events
  • prepared through training and education to participate in open disclosure
  • supported through the open disclosure process.
  1. Integrated clinical risk management and systems improvement

Thorough clinical review and investigation of adverse events and adverse outcomes should be conducted through processes that focus on the management of clinical risk and quality improvement. Outcomes of these reviews should focus on improving systems of care and be reviewed for their effectiveness. The information obtained about incidents from the open disclosure process should be incorporated into quality improvement activity

  1. Good governance

Open disclosure requires good governance frameworks, and clinical risk and quality improvement processes. Through these systems, adverse events should be investigated and analysed to prevent them recurring. Good governance involves a system of accountability through a health service organisation’s senior management, executive or governing body to ensure that appropriate changes are implemented and their effectiveness is reviewed. Good governance should include internal performance monitoring and reporting.

  1. Confidentiality

Policies and procedures should be developed by health service organisations with full consideration for patient and clinician privacy and confidentiality, in compliance with relevant law (including federal, state and territory privacy and health records legislation). However, this principle needs to be considered in the context of Principle 1: Open and timely communication.

KEY ELEMENTS OF THE OPEN DISCLOSURE PROCESS

  1. Detecting and assessing incidents
  • Detect adverse event through a variety of mechanisms
  • Provide prompt clinical care to the patient to prevent further harm
  • Assess the incident for severity of harm and level of response
  • Provide support for staff
  • Initiate a response, ranging from lower to higher levels
  • Notify relevant personnel and authorities
  • Ensure privacy and confidentiality of patients and clinicians are observed
  1. Signalling the need for open disclosure
  • Acknowledge the adverse event to the patient, their family and carers including an apology or expression of regret.
  • A lower level response can conclude at this stage.
  • Signal the need for open disclosure
  • Negotiate with the patient, their family and carers or nominated contact person
    • the formality of open disclosure required
    • the time and place for open disclosure
    • who should be there during open disclosure
  • Provide written confirmation
  • Provide a health service contact for the patient, their family and carers
  • Avoid speculation and blame
  • Maintain good verbal and written communication throughout the open disclosure process
  1. Preparing for open disclosure
  • Hold a multidisciplinary team discussion to prepare for open disclosure
  • Consider who will participate in open disclosure
  • Appoint an individual to lead the open disclosure based on previous discussion with the patient, their family and carers
  • Gather all the necessary information
  • Identify the health service contact for the patient, their family and carers (if this is not done already)
  1. Engaging in open disclosure
  • Provide the patient, their family and carers with the names and roles of all attendees
  • Provide a sincere and unprompted apology or expression of regret including the words I am or we are sorry
  • Clearly explain the incident
  • Give the patient, their family and carers the opportunity to tell their story, exchange views and observations about the incident and ask questions
  • Encourage the patient, their family and carers to describe the personal effects of the adverse event
  • Agree on, record and sign an open disclosure plan
  • Assure the patient, their family and carers that they will be informed of further investigation findings and recommendations for system improvement
  • Offer practical and emotional support to the patient, their family and carers
  • Support staff members throughout the process
  • If the adverse event took place in another health service organisation, include relevant staff if possible.
  • If necessary, hold several meetings or discussions to achieve these aims
  1. Providing follow-up
  • Ensure follow-up by senior clinicians or management, where appropriate
  • Agree on future care
  • Share the findings of investigations and the resulting practice changes
  • Offer the patient, their family and carers the opportunity to discuss the process with another clinician (e.g. a general practitioner)
  1. Completing the process
  • Reach an agreement between the patient, their family and carers and the clinician, or provide an alternative course of action
  • Provide the patient, their family and carers with final written and verbal communication, including investigation findings
  • Communicate the details of the adverse event, and outcomes of the open disclosure process, to other relevant clinicians
  • Complete the evaluation surveys
  1. Maintaining documentation
  • Keep the patient record up to date
  • Maintain a record of the open disclosure process
  • File documents relating to the open disclosure process in the patient record
  • Provide the patient with documentation throughout the process

 

KEY COMPONENTS OF OPEN DISCLOSURE DISCUSSIONS

  1. Introductions
  • The patient, their family and carers is told the name and role of everyone attending the meeting, and this information is also provided in writing.
  1. Saying sorry

A sincere and unprompted apology or expression of regret is given on behalf of the healthcare service and clinicians, including the words ‘I am’ or ‘we are sorry’. Examples of suitable and unsuitable phrasing of an apology are provided in the resource titled Saying Sorry: a guide to apologising and expressing regret in open disclosure available at www.safetyandquality.gov.au/opendisclosure

  1. Factual explanation: providers

A factual explanation of the adverse event is provided, including the known facts and consequences of the adverse event, in a way that ensures the patient, their family and carers understand the information, and considers any relevant information related earlier by the patient, family and carers. Speculation should be avoided.

  1. Factual explanation: patient, family and carer(s)

The patient, family and carers have the opportunity to explain their views on what happened, contribute their knowledge and ask questions (the patient’s factual explanation of the adverse event). It will be important for the patient, their family and carers that their views and concerns are listened to, understood and considered.

  1. Personal effect of the adverse event

The patient, family and carers is/are encouraged to talk about the personal effect of the adverse event on their life.

  1. Plan agreed and recorded

An open disclosure plan is agreed on and recorded, in which the patient, their family and carer(s) outline what they hope to achieve from the process and any questions they would like answered. This is to be documented and filed in the appropriate place and a copy provided to the patient, their family and carers.

  1. Pledge to feed back

The patient, their family and carers is assured that they will be informed of any further reviews or investigations to determine why the adverse event occurred, the nature of the proposed process and the expected time frame. The patient, their family and carers are given information about how feedback will be provided on the investigation findings, by whom and in what timeframe, including any changes made to minimise the risk of recurrence.

  1. Offer of support

An offer of support to the patient, their family and carers should include:

  • ongoing support including reimbursement of out-of-pocket expenses incurred as a result of the adverse event
  • assurance that any necessary follow-up care or investigation will be provided promptly and efficiently
  • in the relevant settings, clarity on who will be responsible for providing ongoing care resulting from the adverse event
  • contact details for any relevant service they wish to access information about how to take the matter further, including any complaint processes available to them
  1. Support for patients and staff

The patient, their family and carers engages in open disclosure with staff. Staff are supported by their colleagues, managers and health service organisation, both personally (emotionally) and professionally, including through appropriate training, preparation and debrief.

  1. Other health service organisations

In cases where the adverse event spans more than one location or service, relevant clinicians and staff will ensure, where possible, that all relevant staff from these additional institutions are involved in the open disclosure process.

 

OTHER CONSIDERATIONS:

It is not necessary to cover every component in the first disclosure meeting. For instance, a full explanation of why an adverse event occurred may not be possible until associated investigations are completed and the causative factors are known.

A written account of the open disclosure meeting should be provided to the patient, their family and carers and a copy filed in the patient record.

 

OUTCOME

Sir John Monash Private Hospital will act in accordance with the Australian Open Disclosure Framework when and if there is an adverse event.