Ramsay Health Care is committed to ongoing improvement of patient care in all areas.

While we
have an excellent record in delivering quality patient care and managing risks, the Company
continues to focus on improvements that will keep it at the forefront of health care delivery. To
this end, Ramsay Health Care prides itself on listening and responding to the needs of our
patients. We continually evaluate and improve on all aspects of our performance through
customer satisfaction surveys and formal feedack processes.
Ramsay Health Care has a strong commitment to safety and quality and this is reflected in our
organisation!wide approach to"
Creating safe environments and systems of work for our staff#
Reviewing and improving on a continuous asis the performance of our patient safety
and quality systems#
$ssisting our healthcare professionals and %isiting &edical 'ractitioners to monitor the
safety and quality of care they provide#
(nsuring accountaility for the safety and quality of care at all levels of our organisation
right through to the )oard of Ramsay Health Care.
The Ramsay Health Care )oard and Risk &anagement Committee endeavour at all times to
fulfil their governance responsiilities y demonstrating strong strategic leadership in safety and
quality, supporting Ramsay Health Care staff and accredited medical practitioners in their efforts
to provide safe, high quality care, and monitoring and responding to the performance of
Ramsay*s patient care systems in oth inpatient and day patient settings.
Ramsay Health Care has developed a comprehensive Clinical +overnance ,ramework ased on
an integrated approach to clinical risk management and continuous quality improvement. This
,ramework measures four ma-or areas of organisational performance including"
1. Clinical Risk Management (making sure our services are safe and minimising risk of
error)
The Ramsay culture promotes and encourages staff to report incidents, risks and near
misses#
.ncident &anagement policy outlines the process for assessing and investigating
incidents#
Ramsay clinical policies are developed in accordance with evidence ased est practice#
Clinical, risk and safety policies are reviewed on a regular asis and updated as required#
and
Ramsay has a strategy and policy for *whistle lowers*
2. Clinical Effectiveness (making sure that the clinical services we provide are effective)
/uality and 0afety .ndicators are used to measure and monitor performance#
/uality plans are initiated when significant issues are flagged#
/uality and 0afety .ndicators are enchmarked nationally#
0erious clinical incidents are reported and investigated#
Clinicians are represented on the +overnance Committee and expert clinical advisory
panels#
High risk areas are audited on a regular asis#
/uality performance and safety issues are reported to the Ramsay )oard# and
$ll facilities meet the standards for accreditation.
3. Effective orkforce (making sure our staff are competent and up!to!date)
,acility Rules are availale to all existing and new medical and allied health personnel#
Ramsay Health Care has a strict process for checking credentials, registration and scope
of practice for all clinical disciplines#
Ramsay has targeted education and competency requirements in all clinical areas with a
particular focus on high risk areas# and
0taff are orientated and updated on quality and risk systems.
1. Consumer 'articipation 2involving our patients and carers in their care3
Consumers participate in our risk management and quality improvement activities#
Consumer complaints and feedack processes are managed in a timely way#
Consumer feedack from Ramsay 'atient 0atisfaction 0urveys informs strategic and
usiness planning# and
4pen disclosure etween clinicians and consumers is actively promoted when things
don*t go to plan.
'erformance across these areas y all Ramsay hospitals is closely monitored y Ramsay*s
Clinical +overnance 5nit and reported through to the Company6s Risk &anagement Committee
and the )oard of Ramsay Health Care.
"ccreditation
$ll $ustralian facilities are accredited using the 7ational /uality 8 Health 0tandards which was
introduced in 9:;<.
$ccreditation is an important driver for safety and quality improvement. Through accreditation
Ramsay Health Care has een ale to assess our level of performance in relation to estalished
national and international standards and to implement ways to continuously improve our service
delivery.
#nfection Rate
(Staph Aureus bacteraemia)
RHC Rate: 0.30/10,000 patient days
Industry Benchmark: 2.000/10,000 patient days
$t Ramsay Health Care we aim to minimise the risk of infection to patients, staff and visitors
that come to our facilities across $ustralia. 4ur infection rates 2aove tale3 has een
consistently elow the industry enchmark and the organisation has a numer of programs in
place to detect and prevent infections that are common within health care facilities. Ramsay
hospitals continue to achieve outstanding results in scheduled infection control compliance
audits conducted y an external provider.
4ne of the most effective means to prevent infection spreading amongst patients is for all health
professionals to wash their hands.
$and $%giene
RHC Rate: 71.4%
Industry Benchmark: 70%
Hand hygiene is conducted in accordance with the *five moments* that is# efore touching a
patient# efore a procedure# after a procedure# after touching a patient and after touching a
patient*s environment.
Ramsay hospitals participate in the national hand hygiene strategy through Hand Hygiene
$ustralia. Hand hygiene audits are conducted three times per year. $ steady improvement in
these compliance audits can e seen over the two reporting periods for 9:;9 and 9:;<. 4ver 1<
+old 0tandard $uditors within Ramsay have received specific training to report audit data to
Hand Hygiene $ustralia.
%isitors to Ramsay facilities are encouraged through appropriate signage to use antiseptic hand
ru located throughout Ramsay Health Care facilities.
&atient 'alls
R$C Rate" :.:9=
#ndustr% (enchmark" :.;;=
The risk of falling increases according to age with data suggesting that one third of people over
the age of >? years have one or more falls a year.
,alls!related in-uries can include minor skin arasions, -oint dislocation, fractures and head
in-uries. These in-uries may 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, the introduction of new
medications and walking in unsafe footwear or slippers.
The Ramsay Health Care falls prevention program targets those patients who we identify as
eing at risk. We use specific criteria and tools to risk assess our patients and then put in place a
numer of strategies to minimise falls whilst in hospital. We do this y educating our staff to
ensure that the patient6s call utton and personal items are in reach# that call ells are attended to
promptly# that patients are assisted to the toilet at regular intervals# and that patients have the
appropriate walking aids. 0ome hospitals provide socks with special grip. Ramsay has purchased
low eds, falls mats and patient alarms to minimise the risk of patients falling whilst in our
hospitals.
)nplanned readmissions
R$C Rate" :.@1=
#ndustr% (enchmark" ;.99=
Ramsay has a low percentage of patients who have an unplanned readmission to hospital
following discharge. &onitoring of this information is very important as it provides an indication
of the effectiveness of our discharge planning processes.
)nplanned return to theatre
R$C Rate" :.<:=
#ndustr% (enchmark" :.<9=
Ramsay Health Care monitors any unplanned return to the operating room within the same
hospital admission. (ach hospital reviews the data collected to identify if any action is required.
$ low rate of return to theatre is desired, however sometimes a return to theatre is unavoidale
and can e a life!saving measure.
Medication *afet%
&edicines are commonly used to treat a variety of conditions in the healthcare setting and
therefore it is important to measure the risk of errors. Ramsay Health Care has a very low rate of
medication errors due to its implementation of a range of medication safety strategies.
Ramsa% Rate" :.::9=
#ndustr% (enchmark" :.:;=
The aove data relates to patients who require medical intervention as a result of a medication
safety incident.
The $ustralian Commission on 0afety and /uality in Health Care has introduced a numer of
safety initiatives for medication administration and reconciliation and Ramsay Health Care has
adopted many of these strategies. This includes the 7ational .npatient &edication Chart which
standardises the documentation on how medicines are prescried and ordered. $doption y
Ramsay Health Care of the 5ser!$pplied Aaelling of .n-ectale &edicines recommendations
has assisted in preventing medication errors related to the wrong route, dose or medication eing
administered.
.n addition Ramsay Health Care has medication administration policies and processes in place
which have een developed using est practice principles.
Ramsay Health Care takes all medication errors very seriously. We encourage staff to report all
errors no matter how minor they may seem. $ll medication incidents are investigated and
actioned and any serious medication incidents are investigated thoroughly and monitored y the
Company6s Clinical +overnance 5nit.
&ressure in+uries
R$C Rate" :.:<=
#ndustr% (enchmark" :.:B=

'ressure in-uries are wounds which form as a result of prolonged pressure to an area of skin.
'ressure in-uries are recognised worldwide as a common cause of harm to patients and could
cause significant pain and discomfort which may result in a slower recovery for the patient.
Ramsay Health Care facilities are well equipped with the latest equipment to assist staff to
prevent these in-uries from occurring. 'atients are risk!assessed on admission using an
evidenced!ased tool. 0taff follow a care plan which is targeted to minimising a patient6s risk of
developing a pressure in-ury for those patients assessed as high risk. This includes inspecting the
patient6s skin frequently, managing moisture, keeping the skin dry, optimising nutrition and
hydration and moving the patient frequently or using special pressure relieving mattresses when
needed.
With these initiatives the incidence of pressure in-uries at Ramsay facilities is well elow the
.ndustry )enchmark for all hospitals for oth reporting periods.
&atient *atisfaction
R$C *core" B1
#ndustr% (enchmark" B<.<
Ramsay Health Care receives feedack from our consumers in a numer of ways. ,ormally, an
independent company carries out an organisation!wide patient satisfaction survey every two
years which provides us with a snapshot in time satisfaction report.
.n 9:;: this independent organisation surveyed over <?,::: Ramsay Health Care patients. The
results of this extensive survey showed that there were significant improvements in the areas of"
nursing care
discharge planning
overall assessment
test and therapies and
care of our visitors and families.
0pecialty areas with the highest customer satisfaction rating were"
Coronary Care
.ntensive Care
0urgery
Ceeping our patients informed on how to voice a complaint and inclusion in decision!making
were identified as areas for improvement. 0ince that time, the organisation has ensured that
every hospital wesite contains a link to the $ustralian Charter of Healthcare Rights and
suggested ways for voicing a complaint.
The next organisation!wide patient satisfaction survey will e conducted in 9:;1.
,ther -ualit% initiatives implemented
$ numer of specific clinical improvement pro-ects were initiated in 9:;; across Ramsay Health
Care. The success of these initiatives have een monitored over 9:;9 and 9:;< and show a
positive increase in patient outcomes.
The Deteriorating Patient
With an increasing proportion of patients admitted to hospital with complex prolems, it is
recognised that these patients are more likely to e or ecome seriously ill during their hospital
stay. Ramsay Health Care focuses on having strong systems and processes in place to identify
early warning signs so that serious events can e avoided or managed proactively.
To this end staff education programs are in place across Ramsay Health Care to assist in
identifying the deteriorating patient and to trigger the appropriate response. Colour!coded charts
enale easy identification when a patient6s vital signs are not within normal limits. &edical
(mergency Teams are activated to respond promptly to a patient who shows signs of
deterioration. (quipment and resources to monitor patients is availale so that the needs of the
seriously ill patient can e addressed in a timely manner.
Ramsay Health Care hospitals have policies in place to assist and guide staff in the management
of the deteriorating patient. 0taff are encouraged to report any incidents relating to the
deteriorating patient. )y trending common contriuting factors we are ale to analyse and
manage this group of patients more effectively.
Risk Reporting Safety Improvements
4ne of the top priorities for Ramsay Health is to reduce the risk of harm to our patients y
understanding what sometimes goes wrong and then to determine how est to prevent it from
reoccurring. This is made possile through our incident monitoring program which allows us to
track incidents, analyse them and make any necessary changes to how we do things. )y updating
and redesigning our incident monitoring program in 9:;; our staff are ale to report and
proactively manage patient incidents, clinical issues, haDards, risks and near misses. The
information that is collected also allows Ramsay*s +roup Clinical +overnance unit 2+C+53 and
Ramsay hospitals to identify where there are common events such as falls, medication errors and
pressure in-uries so that trends can e identified and e managed appropriately and in a timely
manner. The monitoring program includes a system y which serious events can e escalated so
that they can e managed quickly and effectively to prevent a reoccurrence. Ramsay Health Care
has a strong reporting culture and all staff are encouraged to report incidents or near misses no
matter how ig or small.
Surgical Safety Checklist
in 9:;; the Ramsay Health Care 0urgical 0afety Checklist was introduced. This is ased on the
est practice initiative of the World Health 4rganiDation 0urgical 0afety Checklist which is
designed to minimise risks to patients who are undergoing surgical and other procedures.
The Checklist ensures the operating team of surgeons, anaesthetists and nurses conduct key
safety checks prior to certain stages of surgery. Together with other safety measures the
Checklist helps us to ensure that we are doing the right operation, on the right patient in the most
appropriate way. .n 9:;< the checklist has een taken up y many procedural areas within
Ramsay therey increasing safety in these areas.