Important Updates for Our Valued Consumers

Updated 5th of July 2023

The wearing of masks in Monash House Private Hospital is now optional for staff, patients, and visitors.

RAT testing is no longer required for patients before admission.

It is important to keep in mind that there is still COVID-19 in the community. Hospital management requests that if you are symptomatic or a close contact of a COVID positive case, that you conduct a RAT to before visit the hospital

Updated 29th October 2021

COVID-19 Informational Brochure

At Monash House Private Hospital, we take your care and safety seriously. 

Please click here to view our informational brochure on COVID-19, self-checks, precautions and what to do next.

COVID-19 Test Required

ALL patients attending the hospital will be required to carry out a Rapid Antigen Test (RAT) prior to their admission. Failure to do this could result in your procedure being cancelled.

Patients who have had COVID-19 within the last 90 days will not be required to do a RAT due to the likelihood of still testing positive post infection.

Visitors

A maximum of 2 visitors are permitted

• Visitors over 18 need to be fully vaccinated or provide a negative rapid antigen test on the day of visitation and wear an N95 mask

• Visitors under 18 need to be fully vaccinated or provide a negative rapid antigen test of the day of visitation

• Up to two care and support visits are allowed each day, with no more than two visitors allowed at one time in hospitals

• You are not able to attend the facility if you or a member of your household have tested positive for COVID-19, if you are deemed a close contact or awaiting a test result

• System in place so that patients nominated transport person is to stay out of the hospital until they are requested by staff to present at the screening station to take the patient home thus to ensure that there are not people entering the hospital unnecessarily.

It is imperative for the safety of our patients and staff to ensure patients/carers attending the facility have not been exposed to COVID-19. If you have been deemed to be a close contact of a person with or suspected of having COVID-19 you will need to follow the DHHS guidelines and your appointment will be rescheduled to meet these requirements. In addition, if a member of your household has COVID-19 or is currently awaiting COVID test results, your procedure will need to be rescheduled. 

What has Monash House Private House put in place to stop COVID-19 entering the hospital?

In the ever-unprecedented environment that COVID-19 has created for our daily working lives we at MHPH, and MPG, have felt it prudent to implement processes and policies to prevent the introduction of COVID-19 to our facilities. The following is a summary of just some of the actions we have taken.

Key Points

• We are continuing to perform surgery in line with the current DHHS restrictions

• All staff will be wearing PPE as per DHHS guidelines in response to COVID-19

• Social distancing is to be maintained at all times

• Visitor restrictions will apply in line with DHHS guidelines and MHPH policies & procedures

• Patients are required to carry out a Rapid Antigen Test prior to procedure where applicable

Personal Protective Equipment (PPE)

All staff wear PPE as per DHHS guidelines in response to COVID-19.

Washing of Hands

All individuals going through the doors of MHPH are required to use the provided alcohol rub or wash their hands with soap and water.

All staff, including medical practitioners, have been required to complete their annual Hand Hygiene Australian (HHA) Online Competency as a priority. In addition, our educator, in consultation with our Infection Control Coordinator (ICC), has given updated education regarding Hand Hygiene to staff. Hand hygiene auditing by our gold star auditor has continued and is being lodged with HHA.

Automatic hand hygiene dispensers have been put in various locations around the building and we are awaiting further instillation of more throughout the hospital.

Pre-Admission Screening

Screening for COVID-19 has also been introduced to pre-admission phone calls and on the day of admission during the admission process. Patients are asked the same questions as at the screening station, if there is a Yes answer to any of the required questions, then the Infection Control Coordinator (or their delegate) is to be contacted for further advice as to whether it is safe to go ahead with the admission or not.

Patients Developing Symptoms in our Care

Guidelines have been developed for staff on what to do if a patient develops symptoms of COVID-19 in our care. This includes consultation on the impact to staffing within the hospital and instigating back up plans to keep the business functioning.

Flu Vaccines

Flu vaccines are available for all staff at MHPH, and MPG, by our immunisation nurse. This immunisation is mandatory and if staff decline, they are to sign a refusal form and wear a mask for all patient contact during the flu season.

Dedicated Infection Control Coordinator

MHPH now has a dedicated Infection Control Coordinator working 4 to 5 days a week to decrease that the impact that COVID-19 has on the business, its staff and consumers.

Communication

Regular updates to staff, medical practitioners and other consumers regarding updates and changes to working routines and environments. 

Communication with Consumers

Constant communication through social media, MHPH website and communication with patients at pre-admission phone calls regarding our actions with COVID-19.

Expectation around visitors, transport home and follow up appointments given both verbally and in writing.

Banners and signage shown around the hospital about hand hygiene, strategies and cough/sneeze etiquette.

Cleaning

MHPH has introduced an extra cleaner dedicated to cleaning thoroughfare areas and frequently touched services within the building.

Checklists have been introduced for cleaners to sign off so that when a task is completed consumers and can see that cleaning has been completed at a certain time and as per hospital policy.

Social Distancing

It is imperative at this time to practise social distancing to stop or slow the spread of infectious diseases. Our waiting rooms have been altered to ensure the current guidelines around social distancing are being met.

For more translated resources on the COVID-19 please see [here].

For more information on COVID-19 and up-to-date announcements, please visit https://www.dhhs.vic.gov.au/coronavirus

We thank you for your cooperation at this time.

My Health Record

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.

• It allows people to take more control of their own health and wellbeing, manage their children’s health, and upload key documents, like emergency contacts and advanced care plan wishes.

• Accessing this information can help prevent doctors ordering unnecessary repeat investigations. It also allows our clinicians to see details of your treatment outside SVHM, providing you with the best possible care quickly.

• Enabling other health professionals you authorise to see your key health summary so you don't have to repeat it or worry about forgetting important information, like medications.

• Helping you and your healthcare providers to better manage complex or chronic conditions

• You can customise access to your My Health Record by setting access controls including restricting who can see your information, or cancel your record, at any time

• You can also look up these details from anywhere with internet access.

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?

Visit www.myhealthrecord.gov.au

Visit the Department of Health and Human Services website

Call the My Health Record Helpline on 1800 723 471 or

Visit a Medicare Service Centre.

Hand Hygiene

“The 5 moments of hand hygiene” are employed at MHPH in accordance with Hand Hygiene Australia are:

1. Before touching a patient

2. After touching a patient

3. Before a procedure

4. After a procedure

5. After touching a patient's surroundings

It is mandatory that all staff complete Hand Hygiene certification annually.

Compliance rate is benchmarked against national compliance rates.

Patients and consumers are encouraged to perform hand hygiene frequently. You will find alcohol-based hand rub available in throughout the hospital.

Good hand hygiene helps reduce the transmission of infection and keep risks down!

COVID-19

Additional strategies have been implemented at MHPH in response to COVID-19 in line with recommendations from both Federal and State health authority regulations:

• Increased screening measures commencing during pre-admission and admission

• Having a screening clerk at hospital entrance conducting temperature checks, surveying and documenting all people coming in to the hospital for traceability purposes

• Social distancing and signage

• Development of policies and procedures and pandemic action plans

• Mandatory COVID-19 education for all staff and regular bulletins/updates

• Increase in PPE and alcohol based hand-rub accessibility

• Consumer information sheets

Antimicrobial Stewardship – Safe and Proper Use of Antibiotics 

Antimicrobials include antibiotics active against bacteria, as well as anti-fungal, anti-viral and anti-parasitic medicines. Inappropriate use of antimicrobials can lead to increases in drug resistance, side effects and treatment costs. An effective approach in hospitals is an organised antimicrobial management program, known as antimicrobial stewardship (AMS).

Why is antimicrobial stewardship important?

Antimicrobials include antibiotics active against bacteria, as well as anti-fungal, anti-viral and anti-parasitic medicines. Inappropriate use of antimicrobials can lead to increases in drug resistance, side effects and treatment costs. An effective approach in hospitals is an organised antimicrobial management program, known as AMS.

What are we doing at Monash House to improve antimicrobial stewardship AMS?

At Monash House, AMS is facilitated by the Infection Control Coordinator with guidance of the Medical Advisory Committee. The antibiotics that the doctors are prescribing are tracked to ensure:

·      There is no over prescribing

·      The correct antibiotic is being prescribed (if required)

·      Patients are involved in the decisions being made about their care

·      Patients are able to access information regarding antibiotics, AMS and their treatment

What can you do?

It is important for healthcare workers, patients, carers and the community to be well-informed about appropriate antimicrobial use, as we all have a part to play. If you would like to learn more please visit the following sites:

Useful Links

·      Clinical Care Standards Antimicrobial Stewardship Consumer Fact Sheet

·      Antibiotics Explained

·      Do I really need antibiotics?

·      NPS MedicineWise – Antibiotic resistance: the facts

• Increasing age

• Medications

• Nutrition

• Hydration

• Cognition and orientation

• Vision

• Medical history

• Incontinence

• Fear of falling

• Physical fitness

• Environmental clutter

Strategies that have been implemented for our Falls Prevention and Risk Management initiative include:

• Increasing staffing numbers particularly in second stage recovery

• Increase in staff supervision

• The provision of lateral support aids in theatre

• Focus on education for both staff and patients

• Posters about Falls Prevention were placed in areas around the ward and in Theatre where falls are most likely to occur

• Education surrounding post-procedural leg weakness

• Increased use of mobility aids such as walking frames

• Making mobility aids available for loan for patients

Remember! You can reduce your risk of falling by using the following strategies:

• After your procedure do not get up without assistance from a healthcare worker. Call for assistance and MOVE SLOWLY- especially if you have had an anaesthetic or any other medication that can cause drowsiness.

• Wear appropriate footwear- shoes or slippers are ideal. Avoid socks without shoes as they have no grip.

• Wear your glasses as applicable and use lights/night lights when dark and keep your surroundings free of clutter.

Zero Tolerance of Violence and Aggression Statement

It is the policy of Monash House Private Hospital and its associated entities that:

1. Doctors, Nurses, Assistant, Reception, Support and Administration staff have the right to work in a safe and healthy workplace free of violence and aggression.

2. Aggressive and violent behaviour toward Doctors, Nurses, Assistant, Reception, Support and Administration staff is unacceptable and should not be tolerated in any workplace.

3. Occupational violence and aggression is any incident in which an employee is abused, threatened or assaulted in circumstances arising out of or during the course of their work and includes:
   

   • Verbal, physical or psychological abuse

   • Threats or other intimidating behaviours

   • Physical attack, such as hitting, pinching or scratching

   • Aggravated assault

   • Threats with a weapon or objects

   • Sexual harassment and sexual assault

4. Aggressive and violent behaviour is not limited to face to face interaction but could be over the phone or in writing via email, letter or fax.

5. The effective prevention and management of violence and aggression in the health care industry is in the interest of all including Doctors, Nurses, Assistant, Reception, Support, Administration staff, patients and their wider community.

6. The source of violence and aggression can be any person including patients, families and friends, members of the public and work colleagues.

Monash House Private Hospital reserves the right to refuse to treat any person that is, or threatens to be, violent or aggressive towards staff, other patients or the general public within its premises or the surrounding area. As required Monash House Private Hospital will report any violent or aggressive behaviour to the relevant authorities for further action.

Open disclosure is the process of open communication with a patient, and or their family support person, following an adverse or unexpected event that may or may not result in harm to the patient.

The open disclosure process provides an ethical framework for ensuring that staff inform patients, and where applicable their support person, in an open, honest and empathetic manner about a patient related incident and its implications for the health care of those patients.

The Open Disclosure Framework provides principles to address the interests of patients, support persons, staff and other key stakeholder groups.

These Include:

• Openness and timeliness of communication

• Acknowledgement of the incidents

• Expression of regret/apology

• Recognition of the reasonable expectations of the patient and their support person

• Staff need for support

• Confidentiality

For more information, click here to download a copy of the full Open Disclosure document.  

Question:
Degree to which I was involved in clinical handover between healthcare workers.

Question:
Degree to which staff checked my identification (asking and checking my identification band)

Question:
Degree to which healthcare workers spoke to me about my medications (medication history, medication reconciliation, discharge medication information).

Question:
Information healthcare workers gave me about follow-up care and discharge instructions

Question:
Hand hygiene of healthcare workers (use of handrub or soap and water).

Question:
My confidence in the safety of my treatment and care.

Clinical Safety and Quality

Click here to download a pdf copy the MHPH Clinical Governance Framework.

Policy Statement

Monash House Private Hospital is committed to delivering excellence in quality care and providing the highest possible levels of patient clinical safety. We understand that working in partnership with our patients, consumers and stakeholders will ensure a positive experience for all people in our care. Our commitment to clinical safety and quality is based on a robust foundation of systems and process that:

• Ensure that open and transparent processes are in place to support the identification and reporting of clinical safety risks and opportunities for improvement

• Foster an organisational culture that seeks to learn from error and continuously improve the quality and safety of our care

• Support our staff to consistently deliver high quality reliable care

• Incorporate processes for working in partnership with our clinicians, consumers and the wider communities we serve.

The Clinical Governance Framework sets out the key policies, systems and process that enables organisational wide accountability for the delivery of quality care. All Monash House Private Hospital services are externally audited by appropriate agencies.

The Monash House Private Hospital Clinical Governance Framework is made up of the following elements:

• Robust processes that manage clinical risk, safety and quality

• Systems that support the identification, notification and investigation of all clinical incidents, risks and near misses

• Policies and procedures that support a culture of open disclosure

• Committees and processes to drive quality improvement and improve clinical effectiveness

• Workforce capability building strategies that support quality care, including competency-based education and training for all staff

• Credentialing processes that incorporate registration checks and scope of practice review

• Routine measurement and review of clinical safety and quality indicators and transparency of information for consumers

• Consumer complaints and feedback management that ensures transparency and respect.

  Monash House Private Hospital has built a culture of clinical safety and quality that is based on an open and transparent partnership with consumers and the key stakeholders. It is through these partnerships, supported by strong leadership, clinical engagement and appropriate use of technology that Monash House Private Hospital will continue to deliver highly reliable quality care and clinical safety.

Monash House Private Hospital is committed to delivering excellence in care and providing the highest possible levels of patient safety. The Clinical Governance Framework sets out the key structures, systems and processes that enable organisation-wide accountability for the delivery of high quality, safe care.

An effective system of clinical governance that operates at all levels of the organisation is essential to ensure continuous improvement in the safety and quality of care. Good clinical governance makes certain that there is accountability and creates a ‘just’ culture that is able to embrace reporting and support improvement.
Working in partnership with our patients and their families and carers is central to identifying safety and quality issues and the solutions that must be implemented.

The goal of Monash House Private Hospital Clinical Governance Framework is to drive behaviours, both individual and organisational, that lead to better patient care and outcomes.

The National Model Clinical Governance Framework (ACSQHC) defines Clinical governance as:

Clinical governance is the set of relationships and responsibilities established by a health service organisation between its state or territory department of health (for the public sector), governing body, executive, clinicians, patients, consumers and other stakeholders to ensure good clinical outcomes. It ensures that the community and health service organisations can be confident that systems are in place to deliver safe and high-quality health care, and continuously improve services.

Clinical governance is an integrated component of corporate governance of health service organisations. It ensures that everyone – from frontline clinicians to managers and members of governing bodies, such as boards – is accountable to patients and the community for assuring the delivery of health services that are safe, effective, integrated, high quality and continuously improving.

As a component of broader systems for corporate governance, clinical governance involves a complex set of leadership behaviours, policies, procedures, and monitoring and improvement mechanisms that are directed towards ensuring good clinical outcomes. The clinical governance system of a health service organisation therefore needs to be conceptualised as a system within a system – a clinical governance system within a corporate governance system.

Under this model, it is important to recognise the following:

• Clinical governance is of equivalent importance to financial, risk and other business governance

• Decisions about other aspects of corporate governance can have a direct effect on the safety and quality of care, and decisions about clinical care can have a direct effect on other aspects of corporate governance, such as financial performance and risk management

• Governing bodies are ultimately responsible for good corporate (including clinical) governance

• Governing bodies cannot govern clinical services well without the deep engagement of skilled clinicians working at all levels of the organisation.

Corporate governance responsibilities:

Components of the Clinical Governance Framework

The Clinical Governance Framework is based on the NSQHS Standards (2nd ed.) – in particular, the Clinical Governance Standard and the Partnering with Consumers Standard. The Clinical Governance Framework has five components. The central component relates to patients and consumers, who are at the centre of the Clinical Governance Framework.

The five components are as follows:

1. Governance, leadership and culture – integrated corporate and clinical governance systems are established, and used to improve the safety and quality of health care for patients

2. Patient safety and quality improvement systems – safety and quality systems are integrated with governance processes to actively manage and improve the safety and quality of health care for patients

3. Clinical performance and effectiveness – the workforce has the right qualifications, skills and supervision to provide safe, high-quality health care to patients

4. Safe environment for the delivery of care – the environment promotes safe and high-quality health care for patients

5. Partnering with consumers – systems are designed and used to support patients, carers, families and consumers to be partners in healthcare planning, design, measurement and evaluation; elements of this component include – clinical governance and quality improvement systems to support partnering with consumers – partnering with patients in their own care – health literacy – partnering with consumers in organisational design and governance.

National Model Clinical Governance Framework

Clinical governance roles

Good clinical governance provides confidence to the community and everyone who works in a health service organisation that systems are in place to support the delivery of safe, high-quality health care. Within a well-governed healthcare organisation, everyone, including frontline clinicians, managers and the governing body, is accountable for their contribution to the safety and quality of care delivered to patients. These roles are as follows:

1. Patients and consumers participate as partners to the extent that they choose. These partnerships can be in their own care, and in organisational design and governance.

2. Clinicians work within, and are supported by, well-designed clinical systems to deliver safe, high-quality clinical care. Clinicians are responsible for the safety and quality of their own professional practice, and professional codes of conduct include requirements that align with the Clinical Governance Framework.

3. Managers (including clinical managers) advise and inform the governing body, and operate the organisation within the strategic and policy parameters endorsed by the governing body. They are primarily responsible for ensuring that the systems that support the delivery of care are well designed and perform well.

4. The governing body is ultimately responsible for ensuring that the organisation is run well and delivers safe, high-quality care. It does this by establishing a strong safety culture through an effective clinical governance system, satisfying itself that this system operates effectively, and ensuring that there is an ongoing focus on quality improvement.

Governance, leadership and culture

The roles and responsibilities for this component of the Clinical Governance Framework relate to the establishment of, and participation in, corporate and clinical governance systems.

Role Responsibilities

Patients and consumers:

• Use organisational systems and processes to contribute to the planning, design and operation of the health service organisation

• Identify opportunities for improvement of the health service organisation and communicate these to relevant individuals or bodies

• Consider taking an active role in the governance of the health service organisation, when opportunities exist.

Clinicians:

• Actively take part in the development of an organisational culture that enables, and gives priority to, patient safety and quality

• Actively communicate their profession’s commitment to the delivery of safe, high-quality health care

• Model professional conduct that is consistent with a commitment to safety and quality at all times

• Embrace opportunities to learn about safety and quality theory and systems

• Embrace opportunities to take part in the management of clinical services

• Encourage, mentor and guide colleagues in the delivery of safe, high-quality care

• Take part in all aspects of the development, implementation, evaluation and monitoring of governance processes.

 
Managers (including clinical managers):

• Actively communicate the commitment of the health service organisation to the delivery of safe, high-quality care

• Create opportunities for the workforce to receive education in safety and quality theory and systems

• Model the safety and quality values of the health service organisation in all aspects of management

• Support clinicians who embrace clinical leadership roles

• Lead the development of business plans, strategic plans, and organisational policies and procedures relevant to safety and quality

• Integrate safety and quality into organisational plans, policies and procedures

• Set up effective relationships with relevant health services to support good clinical outcome.

 
Staff:

• Staff at Monash House Private Hospital take responsibility for promoting the health, safety and security of patients and carers, the public, colleagues and themselves and to contribute to a positive patient experience.

• Are encouraged to suggest and implement improvements in their wards, areas and departments.

• All staff are expected to work within their scope of practice.

 
Patients and carers:

• Patients and carers in partnership with their healthcare providers, are responsible for participating in shared decision making about their treatment and can promote quality by raising concerns about the safety or effectiveness of the care they are receiving.

• Patients and carers are encouraged to tell us about their experience and suggest improvements to our services.

REFERENCES

Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework. Sydney: ACSQHC; 2019.

A pressure injury (also called a ‘bed sore’ or ‘ulcer’) is a painful wound that affects the skin and the flesh under it.

Your skin may:

• look blistered

• change colour, usually to red

• feel hard or puffy

• feel warm

• break or split.

What to do?

1. Move! Move! Move!

2. Check your skin

3. Eat right!