Lakeside Clinic

Patient Safety & Quality

Lakeside Clinic 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, our hospital continues to focus on improvements to ensure that our services are as safe as possible and that we are minimising risks at all times.

 Lakeside Clinic has a strong commitment to safety and quality and this is reflected in our approach to:

  • Creating safe environments and systems of work for our staff;
  • Reviewing and improving on a continuous basis the performance of our patient safety and quality systems;
  • Assisting our healthcare professionals and Visiting Medical Practitioners to monitor the safety and quality of care they provide;
  • Ensuring accountability for the safety and quality of care at all levels of our organisation reporting through to the Board of Ramsay Health Care.

Lakeside Clinic operates under Ramsay Health Care’s comprehensive Clinical Governance Framework based on an integrated approach to clinical risk management and continuous quality improvement. This Framework measures four major areas of organisational performance including:

1. Clinical Risk Management (making sure our services are safe and minimising risk of error)

  • Our culture promotes and encourages staff to report incidents, risks and near misses;
  • Incident Management policy outlines the process for assessing and investigating incidents;
  • Clinical policies are developed in accordance with evidence based best practice;
  • Clinical, risk and safety policies are reviewed on a regular basis and updated as required; and
  • Strategy and policy for 'whistle blowers'

2. Clinical Effectiveness (making sure that the clinical services we provide are effective)

  • Quality and Safety Indicators are used to measure and monitor performance;
  • Quality plans are initiated when significant issues are flagged;
  • Quality and Safety Indicators are benchmarked nationally;
  • Serious clinical incidents are reported and investigated;
  • Clinicians are represented on the national Governance Committee and National Working Parties;
  • High risk areas are audited on a regular basis;
  • Quality performance and safety issues are reported to the Ramsay Board; and
  • All facilities meet the standards for accreditation by ACHS/ISO.

3. Effective Workforce (making sure our staff are competent and up-to-date)

  • Facility Rules are available to all existing and new medical and allied health personnel;
  • Ensuring a strict process for checking credentials, registration and scope of practice for all clinical disciplines;
  • Targeted education and competency requirements in all clinical areas with a particular focus on high risk areas; and
  • Staff are orientated and updated on quality and risk systems.

4. Consumer Participation (involving our patients and carers in their care)

  • Consumers participate in our risk management and quality improvement activities;
  • Consumer complaints and feedback processes are managed in a timely way;
  • Consumer feedback from patient satisfaction surveys informs strategic and business planning;
  • Consumer participate and partner in improving patient experiences and health outcomes;
  • Health and safety performance is publicly available on hospital website; and
  • Open disclosure between clinicians and consumers is actively promoted when things don't go to plan.

Our Safety & Quality Performance

The following table provides the most recent performance for Lakeside Clinic.

Hospital Performance
Public Peer Aggregate Rate
Patient Safety & Quality Indicators
Infection Rate (per 10,000 bed days) (Staph Aureus bacteraemia)
Hand Hygiene
Patient Falls (requiring intervention)
Unplanned return to theatre
Unplanned readmission to hospital within 28 days
Medication Safety Errors
Patients developing pressure injuries whilst in hospital
Patient Satisfaction
Jan - Dec 2015
Jul - Dec 2014
Mar - Jun 2015
Jul - Dec 2014
Jul - Dec 2014
Jul - Dec 2014
Jul - Dec 2014
Jul - Dec 2014

NA = Not available at this time
NR = KPI is not relevant to this facility


All Australian facilities are accredited using the National Quality & Health Standards which was introduced in 2013.

Accreditation is an important driver for safety and quality improvement. Through accreditation Ramsay Health Care has been able to assess our level of performance in relation to established national and international standards and to implement ways to continuously improve our service delivery.

Infection Rate

(Staph Aureus bacteraemia)
At Lakeside Clinic we aim to minimise the risk of infection to patients, staff and visitors who come to our facility. This hospital has a number of programs in place to detect and prevent infections that are common within health care facilities.

One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands.

Hand Hygiene

Hand hygiene is conducted in accordance with the ‘five moments’ that is; before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment.
Lakeside Clinic participates in the national hand hygiene strategy through Hand Hygiene Australia. Hand hygiene audits are conducted three times per year.

Visitors to this hospital are encouraged through appropriate signage to use antiseptic hand rub located throughout the hospital.

The Hand Hygiene brochure has more information on hand hygiene.

Patient Falls

The risk of falling increases according to age with data suggesting that one third of people over the age of 65 years have one or more falls a year.

Falls-related injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries 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.

Our falls prevention program targets those patients who we identify as being at risk. We use specific criteria and tools to risk assess our patients and then put in place a number of strategies to minimise falls whilst in hospital. We do this by educating our staff to ensure that the patient’s call button and personal items are in reach; that call bells are attended to promptly; that patients are assisted to the toilet at regular intervals; and that patients have the appropriate walking aids.

Our Falls Prevention brochure entitled 'Keeping on your Feet' has more information on preventing falls.

Unplanned return to theatre

We monitor any unplanned return to the operating room within the same hospital admission and review the data collected to identify if any action is required. Obviously, a low rate of return to theatre is desired, however sometimes a return to theatre is unavoidable and can be a life-saving measure.

Unplanned Readmission to Hospital within 28 Days

Our hospital reviews patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge planning processes.

Medication Safety

Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors.  Lakeside Clinic is continually reviewing and implementing a range of medication safety strategies to further improve performance in this area.

The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and Lakeside Clinic has adopted many of these strategies. This includes the National Inpatient Medication Chart which standardises the documentation on how medicines are prescribed and ordered.  Adoption by Lakeside Clinic of the User-Applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered.

In addition, Lakeside Clinic has medication administration policies and processes in place which have been developed using best practice principles.

Lakeside Clinic takes all medication errors very seriously. We encourage staff to report all errors no matter how minor they may seem. All medication incidents are investigated and actioned and any serious medication incidents are investigated thoroughly and monitored by the national Clinical Governance Unit.

Pressure injuries

Pressure injuries are wounds which form as a result of prolonged pressure to an area of skin. Pressure injuries 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.

Lakeside Clinic is well equipped with the latest equipment to assist staff to prevent these injuries from occurring. Patients are risk-assessed on admission using an evidenced-based tool.  Staff follow a care plan which is targeted to minimising a patient’s risk of developing a pressure injury for those patients assessed as high risk. This includes inspecting the patient’s 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.

Our Pressure Injury Prevention brochure has more information on preventing pressure injuries.

Patient Satisfaction

Lakeside Clinic focuses on listening and responding to the needs of our patients. Your feedback allows us to continually evaluate and improve on all aspects of our performance.

We encourage feedback from our patients via our website; or via our patient satisfaction surveys.  It is advisable that you express your concerns before you leave the hospital so we can fix any problems for you. The nurse in charge of your ward is a good start but if you remain concerned please ask to speak to a Director or Assistant Director of Nursing/Clinical Services.

Alternatively, there are a number of other ways that you can voice a concern. Our website contains a link to the Australian Charter of Healthcare Rights and this suggests a number of ways for you to express your concerns.

Awards & Recognition

For more information on Safety and Quality Performance of Ramsay hospitals.