Monash House Private Hospital is fully accredited for the National Safety and Quality Health Service (NSQHS) Standards and operates under a Private Hospital License.
The following table outlines how we address each Standard to ensure optimal patient safety and quality of care.
For more details or to view our certificates and current licenses, please contact info@monashhouse.com.au or call 03 8394 0700 and ask for our Customer Service Manager.
We have robust governance systems that are regularly reviewed to maintain and improve care quality and patient outcomes.
Our Clinical Quality and Safety Committee (CQSC) includes hospital executives, nursing and technical staff, our customer service manager and a consumer representative. This committee oversees our safety and quality systems and has the ability to co-op other specialist members and consumers as desired.
Incident reporting including open disclosure processes are in place, with severe incidents reported to health authorities as required.
Clinical indicators (such as cancellations after admission, medication errors, infections, transfers off site and falls) are measured and benchmarked against published data.
Internal audits schedules and task list planned annually and ensure that ongoing compliance in monitoring against all areas of the National Standards occurs. Reports from these audits and tasks are tabled at our CQSC meetings
How did we do in 2025?
In 2025, we conducted four CQSC meetings, admitted over 7000 patients, and had no sentinel events or significant adverse event.
See our July to December 2025 patient demographic data here.
Monash House Private Hospital encourages active participation from patients and carers in all aspects of care and service improvement. We are committed to the Australian Charter of Healthcare Rights, Child Safety, and Privacy Principles.
All patients are invited to provide feedback through formal and informal channels. A variety of platforms are available for this purpose – website link, paper feedback forms at reception and text messages with a link for feedback sent to all patients post discharge.
We distribute Patient Experience Surveys regularly. These are based on The Australian Hospital Patient Experience Question Set (AHPEQS) and collated with results analysed and presented to the CQSC.
All feedback received is de-identified and tabled at our CQSC.
Please contact our team If you are interested in participating in our safety and quality governance. Email info@monashhouse.com.au or call 03 8394 0700 and ask for our Customer Service Manager.
The most recent results from our patient feedback survey are displayed in our reception waiting room and available here.
Monash House Private Hospital has a comprehensive infection prevention and control program in place. Reprocessing of reusable medical devices occurs in our specialist sterilising department in accordance with AS5369:2023 standards. (Reprocessing of reusable medical devices and other devices in health and non-health related facilities) and the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019).
Monash House Private Hospital apply strict Antimicrobial Stewardship (AMS) and monitor post-operative infection rates, submitting results to relevant professional bodies. The results from our November 2025 AMS audit showed 15% of our patients received antibiotics, 100% of which were compliant with our formulary.
Our facility participates in the National Hand Hygiene Initiative (NHHI), and conducts regular audits to assess compliance with the 5 moments of hand hygiene. Our results from the last audit period in 2025 are compared with the National data below:
Governance systems are in place to prevent medication incidents and ensure safe, effective use of medicines. Patients may be prescribed medications (such as opioids for post-operative pain), with clear information provided. Staff and pharmacists are available for consultation regarding medications. Medication errors if they occur are reported through our incident reporting system and reported at the CQSC.
In 2025 we have had minimal medication incidents reported of which none were adverse events that caused harm. There were no trends noticed, these incidents were managed through one-on-one staff education and performance counselling where required.
We implement best-practice clinical pathways, starting with thorough pre-assessment to ensure safe, appropriate care. Patients are actively involved in discussing their goals of care with their doctors. Detailed pre- and post-operative information is provided to empower patients and facilitate safe discharge and follow-up. In 2025, all information was reviewed by a consumer representative and updated as needed.
Due to the patient cohort we need to be particularly careful to prevent slips, trips and falls. Some of the interventions that we have implemented this year include:
At time of writing we are currently at 260 days with no falls. Our falls have reduced by 75% since 2021-2024 when analysed by falls per patient
Our governance systems mandate structured clinical handovers, accurate patient identification, and correct matching of patients with their intended treatment.
We follow the World Health Organisation (WHO) Surgical Safety Checklist recommendations and implement this as a Team Time Out procedure. This process is audited regularly through our internal process audit and medical records audit.
We have done some work surrounding patient identification and patient matching where we will get you to verify your three patient identifiers by telling us your details instead of it being read to you to avoid any mistakes occurring.
Monash House Private Hospital is exempt from this standard
We have robust systems for recognising and responding to clinical deterioration. Appropriate protocols ensure rapid response and safe patient outcomes.
In 2025, we transferred two patients to another facility for ongoing care. These incidents are reported to our CQSC which then feeds into our Medical Advisory Committee, who have a standing agenda for the monitoring of the transfer of patients. We believe that more efficient processes within our pre admission department has contributed to less transfers out by properly screening our patients prior to admission. Two patient transfers over the course of 2025 is considered to be a very low rate in comparison to Australian Council of Healthcare Standard Clinical indicators sets for like organisations.
We welcome patient and carer involvement in our Safety and Quality initiatives. If you wish to participate or provide feedback, please contact us directly.
Our team is ready to answer any questions you have about safety and quality at Monash House Private Hospital. Please do not hesitate to ask for assistance at any time. For further details, info@monashhouse.com.au or call 03 8394 0700 and ask for our Customer Service Manager.
**Monash House Private Hospital**
**Notice to Patients and Carers: COVID-19 and Respiratory Illness Precautions**
At Monash House Private Hospital, protecting the health and safety of our patients, carers, staff, medical practitioners, and the wider community remains our highest priority.
As COVID-19 and other respiratory infections continue to circulate, we strictly follow state health directives alongside established infection prevention and control protocols. To maintain a safe environment, all patients will be screened prior to admission in accordance with current guidelines.
Our standard precautions include:
For more detailed information, infection control resources and signage are displayed throughout our hospital.
Thank you for your cooperation in helping us maintain a safe healthcare setting for everyone.
My Health Record is the name of the national digital health record system. It is sometimes referred to as an e-health record (EHR). Any patient with a Medicare number can register to have one. My Health Record was previously known as the Personally Controlled Patient Record (PCEHR). It does not replace existing medical records but provides an additional, secure online summary.
WHAT ARE THE BENEFITS?
Every year, the average Australian has 22 interactions with the health care system, including visits to GPs, hospitals and specialists. My Health Record can enable your clinicians to access information about your care and treatment, quickly and securely. This can include important details such as allergies, medical conditions, medication details, test results and organ donation decisions.
HOW IS MONASH HOUSE PRIVATE HOSPITAL INVOLVED?
Monash House Private is working towards implementing systems that can provide clinical information into the My Health Record. This will enable clinicians to access records at the point of care and seek to improve the safety and quality of health care for our patients.
HOW DO I GET MORE INFORMATION?
To truly understand our patients’ journey at Monash House, there’s no better approach than seeking your perspective! Your feedback is the cornerstone of our commitment to meaningful engagement and service enhancement. Our aim is to ensure you not only feel heard but also have unwavering confidence that exceptional care awaits you every time you enter our doors.
We’re an independent private hospital, so your feedback and suggestions can lead to swift and effective change in our hospital. We appreciate all feedback about the services that we provide and the way in which it is delivered. The feedback provided is confidential and will not affect your experience.
Should you or your family wish to discuss any concerns during your stay, please discuss this with the Nurse Unit Manager in the first instance. If there are further aspects of your care that you are not happy with please contact the Director of Nursing, Priscilla Guy, via info@monashhouse.com.au or fill in the form below. If your complaint is unresolved you can contact the Health Complaints Commissioner, Level 26, 570 Bourke St, Melbourne, Victoria, 3000, Australia. Phone: 1300 582 113
Fill out the form below with anything you’d like us to know.